26卷6期

• Link 綜論 Review Article
• 以追求身心完美為名：生活機能醫藥對健康照護的危害In the Name of Pursuing Betterness: The Potential Menance of Lifestyle Medicines to Health
• 丁志音、劉芳助、李袖瑜
  Chih-Yin Lew-Ting, Fang-Zhu Liu, Hsiu-Yu Li
• 生活機能醫藥 ； 健康強化科技 ； 健康照護牟利化 ； 醫療化
  Lifestyle medicines ; health enhancement technology ; profitalization of health care ; medicalization
• 2自1998年繼sildenafil（Viagra威而剛）及其後fluoxetine（Prozac百憂解）的問世及使用的急速狂升後，類似的藥物便廣泛被應用於諸多生活方式問題的介入，以便修飾、提升身心的狀態，來強化外觀的、認知及心理的、社會的特殊功能的表現，試圖達到特定或整體的完美與快樂。本文以生活機能醫藥為例，來探討健康強化科技的興起對醫療照護體系甚至人類生活所帶來的衝擊。除了提出生活機能醫藥的定義與範疇外，本文主要由三個層面來探討生活機能醫藥對健康照護體系與人類健康的長遠影響：操弄需求與創造市場、對醫療照護的衝擊與挑戰、以及超越醫療照護的人類本質改變。綜合言之，健康強化科技如生活方式醫藥者，涉及龐大的商業利益，可使健康照護體系與醫學專業產生徹底的質變。除了危及病人安全與真正疾病治療的品質之外，將邁向無止境的人體甚至情緒與心性改造，其終極作用，難於估量。政策制訂者及學術界宜開始關切相關科技產品的使用趨勢與可能影響，並應著手發展管制措施。
  Since 1998 when sildenafil (Viagra) and fluoxetine (Prozac) were first presented and subsequently increased rapidly in use, lifestyle drugs as such have been widely used to tackle various lifestyle problems, aiming to modify and enhance the state of mind and body. This article takes the lifestyle medicines as an example to elucidates how health enhancement technologies may influence health care system and human health. In addition to exploring the definition and scope of lifestyle medicines, the article examines the following three aspects pertaining to the issue: needs manipulation and the creation of markets, impacts on health care system, and, beyond health care, the alteration of human essence. In sum, Health enhancement technology such as lifestyle medicines could change the imperatives of health care system and the nature of medicine, not only endangering patient safety and quality of care but also turning to an everlasting modification in human body and mind. Health policymakers and the academic community should begin investigating the current consumption of lifestyle medicines and its possible impacts, and develop regulatory policies accordingly.
• 443 - 451
• 10.6288/TJPH2007-26-06-01

• Link 原著 Original Article
• 醫療工作的壓力源感受量表之設計及信效度檢定Development and Evaluation of Validity and Reliability of a Questionnaire on Medical Workers' Stress
• 史麗珠、張薰榕、劉孟茹、鄭秀貴
  Lai-Chu See, Hsun-Jong Chang, Meng-Ju Liu, Hsiu-Kuei Cheng
• 醫療工作 ； 壓力源 ； 信效度
  medical workload ; source of stress ; validity and reliability
• 目標：健保支付制度不斷改變，醫療院所均節省人事開銷，醫療人員的工作壓力遽增。過去研究多採用職業壓力指標第二版問卷(OSI-2)的壓力源感受量表，但此量表未依醫療工作的特性設計。因此我們參考OSI-2的壓力源感受量表，擬定「醫療工作的壓力源感受量表(QMWS)」，並進行信效度的評估。方法：QMWS的8個題目：維持醫療院所的營運、應付醫院評鑑工作、病患病情穩定度、與病人關係的維持、面對醫療糾紛、薪水的給付制度、個人考核的制度、升等或學術研究。結果：13位專家的評分皆在4分以上。兩週再測信度的相關係數r=0.85。以OSI-2的壓力源感受量表為金字標準效標，r在0.48至0.67間。以職業倦怠－醫療行業調查(MBI-HSS)的情緒耗竭及去人性化向度來評估QMWS的輻合效度，r分別為0.37、0.16。又OSI-2的工作滿意度、身、心健康量表評估QMWS的分歧效度，r在－0.31至－0.38間。QMWS的Cronbach's α為0.84。結論：QWMS具良好的內容效度、同時效標效度、建構效度、兩週的再測信度，內在一致性。期望這份問卷能廣泛被採用，成果也能互相比較。
  Objectives: Due to the constant changes in the payment systems of the National Health Insurance, hospitals have had to cut the cost of personnel, which has resulted in an increase in stress among the medical workers. Although the second Chinese version of the Occupational Stress Indicator (OSI-2) is commonly used in research, questions about workload for medical workers are not included. Hence, we followed the format of the OSI-2 and designed a questionnaire to assess medical workers’ stress (QMWS). The reliability and validity of the QMWS were examined. Methods: There are eight questions in the QMWS, as follows: 1) running the hospital, 2) preparing the hospital for accreditation, 3) maintaining patients’ disease conditions, 4) maintaining a good relationship with patients, 5) managing medical disputes or lawsuits, 6) paying employees' salaries, 7) having a good job performance, and 8) seeking a job promotion or doing academic research. Results: The average rating by 13 experts of the QMWS was >4. The two-week test-retest reliability was 0.85. The correlation coefficient, r, between the QMWS and the source of stress in the OSI-2 was between 0.48 and 0.67. Emotional exhaustion and depersonalization according to the Maslach Burnout Inventory-Health Service Survey (MBI-HSS) served as a convergent validity and a significant r (0.37 and 0.16, respectively) was observed. Job satisfaction, physical health, and mental health in the OSI-2, and personal accomplishment in the MBI-HSS, served as a divergent validity and a significant r (-0.31 to -0.38) existed. The Cronbach's alpha for the QMWS was 0.84. Conclusions: The QMWS has a good content, concurrent criteria, construct validity, test-retest reliability, and internal consistence. We welcome other researchers to use the QMWS so that findings can be compared on the same basis.
• 452 - 461
• 10.6288/TJPH2007-26-06-02

• Link 原著 Original Article
• 台灣南部健檢成人骨質疏鬆症之盛行率與危險因子探討Prevalence and Risk Factors of Osteoporosis among Adults Undergoing Health Examinations in Southern Taiwan
• 葉慶輝、葉淑娟
  Ching-Hui Yeh, Shu-Chuan Jennifer Yeh
• 健康檢查 ； 骨質疏鬆
  health examination ; osteoporosis
• 目標：台灣老年人口持續增加，骨質疏鬆症病患亦逐年增加，其衍生之相關骨折，勢必對台灣醫療造成更大的負擔，本研究乃針對成人骨質疏鬆與相關因子做分析探討，以提供成人保健政策規劃與後續研究參考。方法：本研究為一橫斷性研究，研究對象為至南部某區域醫院體檢之1,082位成人。資料收集主要包括個人基本特性、生活型態、過去病史、檢驗結果等相關因子，並做描述性與卡方統計分析探討，達統計相關變項則進一步執行多變項邏輯式迴歸分析。結果：在1,082位成人中，平均年齡為69.5±12.1歲，骨質疏鬆盛行率為18.5%。卡方檢定結果發現：個人基本特性（包括年齡、子女數、停經女性、肥胖程度…等）、生活型態（包括抽菸、運動、日常交通工具…等）、過去病史（心血管疾病、白內障、糖尿病、…等）及檢驗結果（BUN尿素氮等）與骨質疏鬆症有關。此外多變項邏輯式迴歸結果顯示老人、體重過輕者、不運動者、日常未使用交通工具代步者、應酬時抽菸者及糖尿病病患，有較大風險會有骨質疏鬆，而戒菸者骨質疏鬆風險相對較低。結論：由結果顯示，台灣隨著老年化之時代來臨，骨質疏鬆人口也日漸增加，提醒成人應注意日常的生活習慣、飲食與自我保健篩檢，以便維持良好的健康，避免不必要之骨折發生。此外，戒菸對骨質疏鬆所帶來之保護作用值得後續研究。
  Objectives: As the aging population is growing, the number of patients with osteoporosis is rising, and the resulting number of osteoporosis fractures will inevitably become an enormous burden on health care in Taiwan. The focus of the current study was to investigate the prevalence and related factors of osteoporosis in adults, the implications of which could provide impetus for further research and planning for health promotion for adults. Methods: The study was a cross-sectional study. Research subjects were comprised of 1082 adults undergoing a health examination in a regional hospital in southern Taiwan. The data collected included socio-demographic variables, lifestyle, history of diseases, and laboratory data. Descriptive and Chi-square tests were used to examine the relationship between osteoporosis and its related factors. Those statistically significant variables were further selected to establish multiple logistic regression models. Results: Among 1082 adults over 40 yrs of age, the average age was 69.5±12.1years and the prevalence of osteoporosis was 18.5%. The results of Chi-square testing revealed that factors, such as socio-demographic variables (including age, number of children, menopause, and obesity status), lifestyle (including smoking, exercise status, and daily transportation), history of diseases (including cardiovascular disease, cataracts, and diabetes), and laboratory data (e.g., renal function [BUN] impairment) had statistical significance with osteoporosis. The results of multiple logistic regression showed that the elderly, the underweight, those who do not exercise, those who walk without vehicles, those who smoke in social venues, and diabetics have a relatively high risk of developing osteoporosis, while ex-smokers had a relatively low risk for osteoporosis. Conclusions: The results of the current study showed that the prevalence of osteoporosis is increasing with the aging society in Taiwan. In order to remain healthy and avoid unnecessary fractures, it is necessary for adults to optimize their personal life styles, maintain diet control, and undergo regular health examinations. In addition, whether or not smoking cessation can protect adults from osteoporosis needs additional research.
• 462 - 471
• 10.6288/TJPH2007-26-06-03

• Link 原著 Original Article
• 出生前後二手菸暴露與嬰兒健康The Effect of Prenatal and Postnatal Environmental Tobacco Smoke Exposure on Infant Health
• 蘇楓喬、李孟智、謝武勳、張蓓貞、郭育良、洪百薰、林秀娟、陳保中
  Feng-Chiao Su, Meng-Chih Lee, Wu-Shiun Hsieh, Pei-Jen Chang, Yueliang Leon Guo, Baai-Shyun Hurng, Shio-Jean Lin, Pau-Chung Chen
• 環境菸煙 ； 出生結果 ； 嬰兒健康
  environmental tobacco smoke ; birth outcomes ; infant health
• 目標：環境菸煙(Environmental tobacco smoke, ETS)是種常見的室內空氣污染，且嬰幼童是暴露於ETS的高危險群。故本研究目的在評估出生前後暴露於ETS，對出生結果，含早產、低出生體重、與small for gestational age(SGA)，及兒童健康，含急診與住院的影響。方法：我們是「台灣出生世代研究(Taiwan Birth Cohort Study)」的前導研究，在母親產後6個月，以自答式問卷訪談了2,048位研究對象，最後共有1,725份含母親及其活產胎兒的完整資料。研究中利用regression models分析出生前後暴露於ETS對出生結果與兒童健康的不良影響，並以test for trend探討暴露於ETS的頻率與兩者間的關係。結果：研究發現母親在懷孕期間暴露到ETS的頻率，會與嬰兒的早產、SGA、急診和住院有顯著相關。再者，懷孕期間或生產後為主動吸菸的母親，會與嬰兒的低出生體重、SGA、急診和住院相關，但該相關除SGA外，其他則在校正後消失。此外，若父親在母親懷孕期間或生產後為主動吸菸者，嬰兒會呈現較高的住院風險，並與父親的抽菸量成正比。最後，研究發現在懷孕期間暴露到ETS的母親，比沒有暴露到的母親其嬰兒之出生體重較少222.3克。結論：在台灣，雖然母親的抽菸率非常低，但研究中仍發現，出生前後所暴露到的ETS會對兒童造成影響。為此，出生前後的ETS暴露在公共衛生上所造成地潛在不良效應，應該更被重視。
  Objectives: Environmental tobacco smoke (ETS) is a common indoor pollutant. Fetuses, neonates, and young children are most at risk from ETS exposure. In this study, we evaluated the relationship of exposure to prenatal and postnatal ETS to birth outcomes (including preterm delivery [PTD], low birth weight [LBW], and small for gestational age [SGA]) and child health outcomes (including emergency visits and hospitalizations). Methods: In this pilot project of the Taiwan Birth Cohort Study, we used a self-reported questionnaire. We interviewed 2,048 mothers 6 months after their deliveries and recruited 1,725 mother-newborn pairs. We analyzed the association of adverse birth outcome and child health with exposure to prenatal and postnatal ETS using regression models, and analyzed relationships between birth outcome and child health and frequency of exposure to prenatal and postnatal ETS using the test for trend. Results: We found a significant association between exposure to ETS during pregnancy and PTD, SGA, emergency visits, and hospitalizations of infants. In addition, infant exposure to ETS via maternal smoking during or after pregnancy contributed to significant crude relationships between LBW, SGA, emergency visits, and hospitalizations, but these relationships were completely explained by the effects of covariates other than SGA. We also observed that paternal smoking during or after pregnancy dose-dependently increased hospitalization risks of infants. Moreover, the mean adjusted BW decrement was 222.3 g in newborns exposed to ETS from maternal smokers. Conclusions: Although maternal smoking risks are very low in Taiwan, prenatal or postnatal ETS exposure still impacts children. Our findings highlight the emerging challenge of prenatal and postnatal ETS exposure to the public health.
• 472 - 481
• 10.6288/TJPH2007-26-06-04

• Link 原著 Original Article
• 台灣老年人活動功能與健康照護費用之關係Physical Functioning and Health Care Costs in an Older Population in Taiwan
• 藍祚運、張新儀、陳慶餘
  Tzuo-Yun Lan, Hsing-Yi Chang, Ching-Yu Chen
• 活動功能 ； 健康照護費用 ； 老年人
  functional status ; health care costs ; elderly
• 目標：過去對於老年人活動功能與醫療服務利用的研究侷限於使用較早期的調查資料、地區性人口、女性，或僅使用日常生活活動功能(ADLs)為功能狀況的測量，且很少有美國之外其他國家的研究資料。我們希望利用台灣的近期健康調查資料，重新檢視老年人功能狀況對健康照護使用的影響。方法：分析2001年「國民健康訪問調查」資料，2,243名60歲以上樣本納入分析。以六項ADLs及九項身體活動的問題測量活動功能。並與全民健保資料庫連結以獲取醫療服務利用資料。統計上利用線性複迴歸分析活動功能與健康照護費用間之關係。結果：分析結果中觀察到功能狀況與照護成本間呈現出清楚的線性關係，且小部份功能嚴重衰退的人耗用了大部分的費用。經過複迴歸模式分析，控制其他相關因素後仍顯示功能狀況與健康照護費用間有顯著的相關性。結論：本研究以台灣本土之全國性調查資料進行分析後，證實老年人活動功能對健康照護的使用有獨立且重要的影響。此研究結果與其他相關研究的發現一致。
  Objectives: Past research involving functional problems and medical utilization has been limited to earlier surveys, local people, women, or use of Activities of Daily Living (ADLs) as the only measure of functional status, and is rarely investigated in non-US countries. We sought to re-examine the effect of functional status on health care utilization in the elderly, using a recent health survey conducted in Taiwan. Methods: 2,243 community-dwelling residents 60 years of age and older in the 2001 National Health Interview Survey (NHIS) in Taiwan were analyzed. Physical function was assessed using six ADLs questions and nine questions involving mobility tasks. The NHIS data were merged with the National Health Insurance claim data. Multiple linear regression was used to model the relationship between functional status and health care costs. Results: A clear gradient relationship between functional status and expenses was observed, with a small proportion of people with declining function responsible for a large proportion of the expenses. Functional status was independently associated with health care expenditures in the multiple regression model. Conclusions: Results from this more recent, non-US, nationwide research support the notion that functional status has an independent contribution to total healthcare expenditures in the elderly across countries.
• 482 - 490
• 10.6288/TJPH2007-26-06-05

• Link 原著 Original Article
• Charlson合併症指數對全民健康保險資料庫適用性之探討Adaptability of Charlson Comorbidity Index (CCI) on the National Health Insurance Research Database
• 柯玲晶、譚醒朝、譚家惠
  Ling-Ching Ko, Sing-Chew Tam, Chia-Hui Tan
• Charlson合併症指數 ； 合併症
  charlson comorbidity index CCI ; comorbidity
• 目標：以全民健保資料庫實証不同合併症指數對病人存活情形解釋力的差異，本研究試以Charlson合併症加權方法與合併症疾病定義，發展適合本國之合併症疾病加權值。方法：以民國90年12月內科住院病人共615人為樣本，收集其住院前11個月西醫門、住診就醫資料及住院後1年存活日期及狀態，參考Charlson制定權重方法產製合併症指數，檢討本研究與Charlson合併症指數對病人存活情形解釋力之差異。結果：同病人僅一種Charlson合併症疾病分類佔37.36%、同時有二種分類佔30.86%、同時有三種分類佔18.18%、同時有四種以上分類佔13.6%。以Charlson原始加權方式可解釋存活月數變異為6.48%；而本研究加權值方式可解釋存活月數變異為9.22%。結論：本研究之加權值可解釋病人存活月數之變異高於原始Charlson合併症指數，其中癌症無論本研究或Charlson之合併症疾病加權方式均為被加權的對象，若有此合併症疾病，會加重就醫時的病情，影響後續治療。
  Objectives: The goal of this study is to adapt the Charlson Index, a measure that takes into account the number and severity of comorbid illnessnes, into a comorbidity index suitable for use in the health care system in Taiwan. Using data from the National Health Insurance Research Database (NHRID), this study examines the effectiveness of various comorbidity indices. Furthermore, the study attempts to develop a weighted comorbidity index suitable for use by the national health care system. Methods: Samples of inpatients hospitalized as of December 2001 were the subjects of the study. Individual data on the number of hospital visits within 11 months prior to hospitalization and the inpatient status after hospitalization were collected. A weighted Charlson comorbidity index was proposed. Next, we compared the effectiveness of the Charlson Index with the weighted Charlson index developed in our study. Results: According to the Cox's regression model, the weighted Charlson Index can explain 6.48% of variability in inpatient status, whereas our approach explains 9.22% of the variability. Conclusions: More variability in inpatient status can be explained by our weighted method than the CCI. In future computations of comorbidity index, one should consider using the weighted index developed in our study.
• 491 - 498
• 10.6288/TJPH2007-26-06-06

• Link 原著 Original Article
• 第二型糖尿病性腎臟病患使用ACEIs/ARBs藥物情形及其相關因素Use of Angiotensin Converting Enzyme Inhibitors and Angiotensin ? Receptor Blockers in Patients with Type 2 Diabetic Chronic Kidney Disease
• 戴嘉伶、朱慧凡、林宏達、吳義勇、吳肖琪
  Chia-Ling Dai, Hui-Fan Chu, Hong-Da Lin, Yee-Yung Ng, Shiao-Chi Wu
• 第二型糖尿病性腎臟病 ； 血管張力素轉化抑制劑 ； 血管張力素受體阻斷劑 ； 末期腎臟病
  type 2 diabetic CKD ; angiotensin converting enzyme inhibitors ; angiotensin ? receptor blockers ; end-stage renal disease
• 目標：糖尿病性腎臟病為末期腎臟病的主要原因之一，國外已有許多研究證實，血管張力素轉化抑制劑(ACEIs)或血管張力素受體阻斷劑(ARBs)對第二型糖尿病性腎臟病患，能減緩末期腎臟病之發生及死亡，本研究目的為暸解第二型糖尿病性腎臟病患使用ACEIs/ARBs藥物情形及其相關因素。方法：以2001年全民健康保險資料庫中尚未發展至第5期之13,673位第二型糖尿病性腎臟病新個案為對象，暸解其ACEIs/ARBs用藥情形。考慮到同一醫師看診下病患有聚集情形，因此以GEE（廣義估計模式）分析影響ACEIs/ARBs用藥之相關因素。結果：2001年第二型糖尿病性腎臟病新個案ACEIs/ARBs用藥率低，初診斷前一年有合併症者其ACEIs/ARBs用藥率較高，其中以併有充血性心衰竭（OR值為1.49，95%信賴區間為1.30-1.72）及高血壓（OR值為1.40，95%信賴區間為1.23-1.60）者ACEIs/ARBs用藥率較高。第二型糖尿病患在地區或基層醫療院所相較於在區域以上醫院就醫、由家醫科或其他科醫師相較於內科及神經專科醫師，在初診斷為慢性腎臟病時被開立ACEIs/ARBs藥物的機率顯著較低。結論：國內第二型糖尿病性腎臟病患ACEIs/ARBs用藥率較國外低。建議國內應藉由醫師繼續教育與民眾衛教宣導，以提高ACEIs/ARBs用藥率。
  Objectives: Diabetic chronic kidney disease (CKD) is one of the main causes of end-stage renal disease (ESRD). Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin ? receptor blockers (ARBs) have been shown to prevent ESRD or mortality among patients with type 2 diabetic CKD. The aim of this study was to investigate the use of ACEIs and ARBs and factors associated with the use of ACEIs and ARBs. Methods: Thirteen thousand six hundred seventy-three new cases of type 2 diabetic CKD below stage 5 were identified in the Taiwan National Health Insurance (NHI) databases in 2001. The factors for ACEIs and ARBs prescription were analyzed by a generalized estimating equation (GEE) for adjusting the cluster effect. Results: ACEIs and ARBs were prescribed less than medically indicated in this cohort. The co-morbidities before CKD was diagnosed were strongly associated with the prescription of ACEIs and ARBs, with adjusted odds ratios (ORs) of 1.49 (95% CI, 1.30-1.72) and 1.40 (95% CI, 1.23-1.60) for congestive heart failure and hypertension, respectively. The prescription rate of ACEIs and ARBs was lower in physician offices and district hospitals than in regional hospitals and medical centers. The prescription of ACEIs and ARBs was more by internists and neurologists than family physicians and other subspecialists. Conclusions: The use of ACEIs and ARBs is lower in Taiwan than expected. Educational efforts to physicians and patients may increase the use of ACEIs and ARBs.
• 499 - 506
• 10.6288/TJPH2007-26-06-07

• Link 原著 Original Article
• 社區失能老人居住安排與日常生活協助未滿足需求之關係Living Arrangement and Unmet Needs of Assistance in Daily Living Among Disabled Elders in the Community
• 熊曉芳、吳淑瓊
  Hsiao-Fang Hsiung, Shwu-Chong Wu
• 未滿足需求 ； 居住安排 ； 日常生活活動 ； 失能老人
  unmet needs ; living arrangement ; activities of daily living ; disable elders
• 目標：了解社區失能老人居住安排及日常生活活動協助未滿足需求現況及影響因素。方法：從「建構長期照護體系先導計畫」實驗社區後測調查，選取1,616位65歲以上日常活動失能老人為樣本，調查其居住安排及基本日常生活活動、行動及工具性日常生活活動未滿足需求，以邏輯斯迴歸檢驗未滿足需求影響因素。結果：具任一項基本日常生活活動、行動及工具性日常生活活動未滿足需求的比率為10.8%、22.6%及8.0%；獨居老人身體功能較佳但未滿足需求較高，行動及工具性日常生活活動未滿足需求以無偶及有使用社區式服務者較高。控制其他變項後發現，居住安排為一重要影響未滿足需求之因素；較之與子女或他人同住，獨居者之未滿足需求勝算比達3-5倍之多。結論：居住安排為影響失能老人未滿足需求重要因素，獨居老人為未滿足需求高危險群，政策應加強社區服務資源以滿足失能老人日常生活活動協助需求。
  Objectives: This study aims to examine the relationship between living arrangement and unmet needs of assistance in BADL (Basic Activities of Daily Living), Mobility and IADL (Instrumental Activities of Daily Living), and to identify factors associated with unmet needs. Methods: Data came from post test survey of the ”Pilot Program for the Development of Long Term Care System”. A total of 1,616 community-dwelling elders who required assistance in at least one item of ADL or IADL were included. Subjects were interviewed by constructed questionnaire for their ADL and IADL assisted needs and unmet needs. Results: The prevalence of unmet needs among elderly in the community was 10.8%, 22.6% and 8.0% on BADL, Mobility and IADL assistance, respectively. Elderly who lived alone were the most vulnerable group on unmet needs, although their functional performances were better than lived with spouse or others. Results of logistic regression analyses indicated that living arrangement was a significant predictor of unmet needs on BADL, Mobility and IADL assistance (reference to live with others, OR=2.74, 5.98, 3.46). In addition, age, education and number of disability were associated with BADL unmet needs. Conclusions: Living arrangement plays an important role in unmet needs of assistance in daily living. Disable elderly live alone are found as at high risk of unmet needs, especially on mobility. Policy maker should pay attention to unmet needs of the most vulnerable group of disabled elderly, aiming at keeping them in the community as long as possible.
• 507 - 517
• 10.6288/TJPH2007-26-06-08