10卷3~4期

• Link 綜論 Review Article
• 子宮頸癌自然病史與台灣子宮頸癌篩檢的文獻回顧Review on Natural History and Screening of Cervical Cancer in Taiwan
• 周碧瑟
  Pesus Chou
• 無
  Review ; Natural history ; Cervical Cancer ; Screening
• 本文針對子宮頸癌自然病史與台灣子宮頸癌篩檢作文獻回顧。子宮頸癌是個持續漸進的疾病，起始於原位癌，經二、三十年後轉變為臨床上的侵襲癌，這自然病史中，在侵襲癌發作之前，約有一、二十年的時間可供偵測或去除。若有篩檢計劃介入，由篩檢發現的無症狀病例會有一段引導期。台灣子宮頸癌篩檢計劃分兩個階段實施，本文描述了計劃內容與主要發現。針對頭十年的篩檢結果之評詁，中華民國防癌協會頭十年的子宮頸癌篩檢計劃已顯現其效果。本文亦估算出1974-1984年間台灣子宮頸癌篩檢計劃的精確度，陽性結果預期值與癌症率。細胞學檢驗室的標準化與品質管制是子宮頸癌篩檢準確性的最重要課題，台灣子宮頸癌的防治有賴於提高受檢率與陽性結果之徹底追蹤診治。
  This article reviews literature of natural history of cervical cancer and cervical cancer screening in Taiwan. Carcinoma of the cervix is a progressive disease beginning with in situ changes and ending 2 or 3 decades later with clinical invasive cancer, and that there is a period of time of approximately one or two decades within this natural history when the disease may be identified, removed, or reversed prior to the onset of invasive cancer. If a screening program is introduced, every asymptomatic case detected in a screening program experiences some lead time. The cervical cancer screening program in Taiwan was carried out in two phases. Program description and major findings were described. The evaluation study suggested that the first ten-year screening program in Taiwan conducted by the Cancer Society of the Republic of China has been effective. The specificity, predictive value, and cancer detection rate of screening for cervical cancer in Taiwan, 1974-1984, were estimated. Standardization and quality control of the cytopathological laboratory is the most important issue in the accuracy of screening for cervical cancer. How to increase the examination rate and complete follow-up for those women with abnormal smears are the key issues in the control of cervical cancer in Taiwan.
• 123 - 131
• 10.6288/JNPHARC1991-10-0304-01

• Link 綜論 Review Article
• “對台灣職業衛生未來推展之建議”“對台灣職業衛生未來推展之建議”
• 莊弘毅、劉益宏、Morton Corn
  Morton Corn
• 無
  none
• 無
  none
• 132 - 135
• 10.6288/JNPHARC1991-10-0304-02

• Link 原著 Original Article
• 中醫師人力及中醫醫療機構現況The Manpower and Facilities of Chinese Medicine in Taiwan
• 李卓倫、賴俊雄、陳太羲、游隆權、詹清旭
  Jwo-Leun Lee, Jim-Shoung Lai, Tai-Hei Chan, Long-Chan Yue, Chin-Shu Tsuan
• 無
  Chinese Medicine ; Health Manpower ; Health Facilities
• 1988年底台灣地區共有2397位執業中醫師，即每位中醫師服務8304人，中西醫師比例1.0:7.6。中醫師的地理分佈存在嚴重的不均。中醫師的年齡集中於30-44歲（佔51%）和70歲以上（佔25%），但各地區中醫師的年齡分佈並無明顯不同。在素質方面，1989年特考及格中醫師中，大學、專科、中小學畢業者各約佔三分之一；在中醫診所中，未受過醫學相開教育特及格者佔60%，受過醫相關教育特考及格者佔30%，中醫系或學士後中醫系畢業者佔2%。 1989年台灣地區共有中醫醫院88家，中醫診所1424家，並均存在嚴重的地理分佈不均。在服務科別上，除了不分科的機構外，平均每家中醫醫院設置4.3科，中醫診所2.7科。在人員配置上，平均每家中醫醫院有5.8位中醫師，4.6位調劑人員，4.5位護理人員；中醫診所有1.1位中醫師，1.4位調劑人員，1.2位護理人員。
  There were 2397 practicing Chinese medical doctors by the end of 1988. Each one served 8304 persons. The number of Chinese medical doctors to that of physicians trained by western method was in the ratio of 1/7.6. The geographical distribution of Chinese medical doctors was quite uneven. The ages were mainly distributed between 30-40 (51%) and over 70 (25%). There were no significant differences in age distribution among different geographical areas. Concerning the background of Chinese medical doctors who passed the special examination in 1989, the university graduates, the junior college graduates and the middle or primary school graduates constituted about 1/3 of the Chinese medical doctors, respectively. Among the clinics of Chinese medicine, 60% of the doctors passed the special examination but never received any medical or paramedical training; 30% of the doctors passed the special examination and had received some medical or paramedical training; only 2% of the doctors had been graduated from department or graduate school of Chinese medicine in China Medical College. In 1989, there were 88 Chinese medical hospitals and 1424 clinics in Taiwan. The geographical distribution was uneven. In average, each hospital had 4.3 departments and each clinic had 2.7 departments excluding those without departments. As to the placement of personnel, each hospital had 5.8 doctors, 4.6 pharmacists and 4.5 nurses in average, while clinic had 1.1 doctors, 1.4 pharmacists and 1.2 nurses
• 136 - 142
• 10.6288/JNPHARC1991-10-0304-03

• Link 原著 Original Article
• 台北地區智障者相關人士對優生保健的認知態度調查Genetichealth
• 張珏、葉安華
  Chueh Chang, An-Hua Yeh
• 無
  Parents of Mental Retarded ; Engenic ; Family Planning
• 本研究目的旨在瞭解我國優生保健法自民國七十四年實施以來，智障兒家長與有機會接觸到智障兒的相關專業人員（特教老師，衛生與社會工作人員），其對於優生保健的了解程度如何？而對於智障兒接受家庭計劃方法，例如服避孕藥、切除子宮、結紮手術等的意願及態度又如何？以期能有效地推動並落實優生保健的理念。 研究對象為12-30歲居住在台北市的智障者之父母們（智障者包括台北市國中益智班、智障發展中心的學生，以及居家的智障者），共二百三十七人；此外，台北市國中益智老師、普通班老師，及衛生與社會福利單位工作人員共兩百人，採問卷訪視方法進行。 研究結果顯示： （一）智障者家長對優生保健的認識有限，有四分之一的家長沒聽過優生保健法，有將近二分之一的家長不知道墮胎已合法化，也不知道各大醫院有優生保健門診。 （二）教育、衛生及社會工作者對於優生保健的了解程度雖較智障者家長為高，但並非完全了解；如對於施行人工流產或結紮手術醫師的資格認定，優生保健門診之服務內容。其中教育工作者的了解程度久低於衛生及社會工作者。 （三）對於智障女孩的避孕方法，多數支持採用「輸卵管結紮」。而有五分之一左右的家長認為輕度的智障女孩沒有必要採行避孕。 （四）多數受訪者贊成對智障男孩施行結紮手衍，但其意願隨著智障程度的減輕而降低。 （五）對於不贊成對智障男孩施行結紮手術者的原因，家長及教育工作者認為智障者若非遺傳所造成，則不會影響到下一代，應無施行手術的必要；而衛生與社會工作者則以會影響智障者身心發展為由而拒絕。
  It will make the population of mental retarded decrease if every one can take advantage of the eugenic examination. Especially those mental retardeds and their families who might have possibility on heridity as well as early pervention on getting preganacy. The purpose of this study is to ivnestigate how much did the parents of the mental retarded and those professional personnel (special education teacher, social and hygiene worker) who had the chance to contact the mental retarded know about the eugenics, as well as to investigate the attitude of the parents and the professionals for having the mental retarded to accept the means of family planning such as oral pill, hysterectomy, sterilization, since 1985 when the Genetic health laws were implemented in Taiwan, Therefore, we can promote the idea of eugenics efficiently. Data were collected via a survey questionnaire. The subjects included 237 parents whose children were 12-30 years old mental retarded living in Taipei, and 100 teachers of Taipei junior high schools & 100 workers of hygiene and social welfare administrations. The results were as follows: 1. Parents' acknowledge of eugenics were limited. 1/4 parents never heard about the Genetic health laws. About 1/2 parents didn’t know that abortion has been legalized and there were eugenic clinics in those teaching hospitals of Taipei city. 2. The professional personnel knew more about eugenics than parents, but not very well. For instance, they knew neither about the qualification of the physicians who can perform sterlizaion and abortion operation for patients nor the contents of eugenic clinics in hospitals very clearly. The knowledge of school educators were less than those health workers. 3. In terms of the contraceptions of the mental retarded girls, most subjects supported the ”Tubal Sterilization”, but there were 1/5 parents conceived that it is not necessary to take contraception. 4. Most subjects agreed to perform the sterilization operation for mental retarded boys, but the intention decreased with the level of mental retardation. 5. As to the reasons of objection to the sterilizaion operation for mental retarded boys, parents and teachers mentioned that of the mental retardaion din't caused by genetics, it wouldn’t influence the offsprings, then it is not necessary to perform the operation. The hygienic and social workers indicated that it would influence the physical and mental development of the mental retarded
• 143 - 154
• 10.6288/JNPHARC1991-10-0304-04

• Link 原著 Original Article
• 鉛回收工廠對附近環境空氣鉛污染之研究Airborne Lead Pollution in the Vicinity of a Lead Recycling Factory
• 陳美蓮、毛義方、藍忠孚、林宜長
  Mei-Lien Chen, I-Fang Mao, Jung-Fu Lan, Yi-Chang Lin
• 無
  ambient air lead pollution ; lead recycling factory
• 為了解鉛相關工業對附近環境空氣的影響，本研究選擇一廢蓄電池回收工廠之半徑五百公尺範圍為研究對象，在距離工廠不同方位和距離放置七部空氣採樣器，作連續24小時之採樣。並在距離工廠最近採樣點放置三部採樣器，作日、夜和24小時之工廠工作日和休假日之採樣，共得樣本80個，結果如下： (1)整個研究區之空氣鉛濃度平均值為1.42±1.55μg/立方公尺，懸浮微粒含鉛量為11,640±11,650μg/g，大部分採樣點之濃度，隨著距離工廠愈遠，污染濃度逐漸下降。 (2)在距離工廠56公尺之採樣點，工廠運轉時間內，日、夜之空氣鉛濃度相近，八個採樣天中，有四天其夜間濃度高於白天濃度。其全日平均達7.58μg/立方公尺，是工廠休息時之26倍，工廠休息時之日、夜濃度分別是0.57μg/立方公尺及0.22μg/立方公尺，全日平均為0.28μg/立方公尺。 本研究顯示該鉛工廠對附速環境空氣為全天性污染型，已造成該地區嚴重之空氣污染。
  To determine the air concentration of lead in the vicinity of a lead recycling factory, we conducted this study by collecting total suspended particulates with Kimoto high volume air sampler and analyzed by atomic absorption spectrometry with a Hitachi 180/70 instrument. The results showed as follows: The lead concentration in the area studied was 1.42±1.55 µg/m^3. The lead content in the suspended particulates was found to be 11,640±11,650 µg/g. The lead level in the air decreased by the distance away from the factory. In average, the lead concentration at night was as high as that in the day time. However, for half of the sampling days, the lead level at night was higher than that of the day time. The average lead concentration for the working day was 7.58 µg/m^3, 26 times that for the holiday.
• 155 - 164
• 10.6288/JNPHARC1991-10-0304-05

• Link 實務 Public Health Practice
• 女性癌症患者之複癌Multiple Primary Cancers in Female Cancer Patients
• 林惠美、黃麗秋、黃思誠、周松男
  Whei-Mei Lin, Lie-Chiou Huang, Su-Cheng Huang, Song-Nan Chow
• 無
  multiple primary cancers ; female cancer patients
• 據台大醫院癌症登記資料顯示：1976年7月至1989年12月，13743個女性癌症個案中，有318個個案為複癌（占2.3%）。其中，有14個個案，其原發部位為3個或3個以上。 十大常見女性複癌，其第一原發部位，依次為子宮頸、乳房、結腸、鼻咽、腎臟、膀胱、直腸、甲狀腺、肺及胃。若以比例來看，則好發複癌之第一原發部位，依次為腎臟(7.5%)、膀胱(6.7%)、陰道及女陰(5.2%)、口腔(4.4%)、結腸(4.1%)、乳房(3.9%)、子宮體(3.3%)喉(2.8%)及子宮頸(2.7%)。 第一原發部位為子宮頸者，其常見之第二原發部位依次為肺、乳房、膀胱、鼻咽、結腸、直腸及骨髓與網狀內皮系統。子宮體癌和卵巢癌常同時出現。而第一原發為陰道及女陰者，常見其第二原發部位發生在子宮頸。 乳房癌常發展出對側乳房、子宮頸、皮膚、肺、結腸、食道及腎臟等第二原發部位。 結腸癌，其第二原發部位，多見於腸胃道（如結腸、直腸、胃及肝），乳房及泌尿生殖器官（如子宮頸、子宮體及膀胱）。 鼻咽癌、其第二原發部位，多發於口鼻部（舌、口腔、鼻腔），腸胃道（結腸、胃、肝）、乳房、子宮頸及皮膚。 腎臟及膀胱癌，常於泌尿生殖系統（腎臟、膀胱、子宮頸及子宮體），發現第二原發癌。 兩個原發癌發生期間之範圍為0至386個月，其中位數為31個月。 第一原發部位接受放射治療或化學治療或兩者都有的比例為54.6%(131/240)。以目前的研究，只能看出放射治療與發生第二原發癌的相關。至於化學治療或兩者組合治療，則與第二原發癌的發生沒有相關。 兩個原發癌發生期間若小於兩個月或超過五年，其五年存活率較好（52.8%及47.8%）。若發生期間在兩個月與五年之間，則其存活率較低(33.6%)。
  During the period July 1976 to December 1989, there were 318 multiple primary cancers among 13,743 female cancer patients (2.3%) seen at this hospital. Fourteen of 318 patients had 3 or more than 3 primary cancers. The ten most frequent female multiple cancers are those arising from cervix uteri, breast, colon, nasopharynx, kidney, bladder, rectum, thyroid, lung and stomach. The primary cancers most likely to develop a second primary cancer are kidney (7.5%), bladder (6.7%), vagina and vulva (5.2%), oral cavity (4.4%), colon (4.1%), breast (3.9%), corpus uteri (3.3%), larynx (2.8%) and cervix uteri (2.7%). Cervical cancer is frequently followed by a second cancer arising from lung, breast, urinary bladder, nasopharynx, colon, rectum, bone marrow and the reticuloendothelial (B.M. & R-E) systems (in the order of decreasing frequency). Corpus cancer usually co-exists with an ovarian cancer. Vaginal and vulvar cancers are also followed by a second cancer arising from the cervix. Breast cancer is frequently followed by a second cancer arising from the contralateral breast, cervix uteri, skin, lung, colon, esophagus or kidney. Colon cancer is frequently followed by a second cancer arising from the gastrointestinal tract (different sites of the colon, rectum, stomach, liver), breast and urogenital organs (cervix uteri, corpus uteri, and. bladder). Nasopharyngeal cancer is frequently followed by a second cancer arising from oral and nasal cavities (tongue, palate, oropharynx, nasal cavity) and gastrointestinal tract (colon, stomach, liver), breast, cervix uteri and skin. Kidney or bladder cancer is frequently followed by a second cancer arising from urogenital organs (kidney, bladder, cervix uteri and corpus uteri). Duration between the occurrence of the first primary and the second primary cancers ranged from 0 to 386 months with a median duration of 31 months. The percentage of patients given radiotherapy and/or chemotherapy for the first cancer was 54.6% (131/240). In the present study, only the association of radiotherapy was observed; the carcinogenic effect of chemotherapy or a combination of radiotherapy and chemotherapy can not be demonstrated. If the duration between the occurrence of the first and second cancer was less than two months or more than five years, the five-year survival rate is better (52.8% or 47.8%, respectively); but if the duration was above two months and less than five years, the five year survival rate is lower (33.6%).
• 165 - 174
• 10.6288/JNPHARC1991-10-0304-06

• Link 實務 Public Health Practice
• 實施丙表前，三所群體醫療執業中心急慢病與牙科醫療費用分析An Analysis of Medical Cost in Group Proup Practice Centers-Foucus on Acute, Chronic and Dental Disease
• 傳振宗、 江東亮、張智仁、陳叔輝、蔣冰然、李世代、謝維銓
  Chen-Chung Fu, Tung-Liang Chiang, Chin-Jen Chang, Shwu-Huei Chen, Bing-Ran Jang, Shyn-Dye Lee, Wei-Chuan Hsieh
• 無
  group practice center ; chronic disease ; acute disease ; medical cost
• 為了明瞭群醫中心牙科與醫科（急慢性病）的疾病分佈，了解其醫療費用的差異，同時比較研究期間，公勞保機關審核醫療給付的方式，我們立意選取三所使用同一套軟體的群體中心，收集民國76年10月1日至77年3月31日共6個月的門診資料，結果發現來診的44859個病例中，以牙科2717例（各6.1%）的每人次平均醫療費用549元最高，而醫科42142個病例(93.9%)的每人次平均醫療費用為323元，其中急性病例為293元，明顯低於慢性病例的361元。群醫中心的每人次平均醫療費用較高的原因，除了牙科費用較高外，群醫中心以照顧中老年人為主是另一原因，由於40歲以上病例占門診所有病例的71.5%，也因此慢性病例佔了41.3%，使得醫療費用增加。若採用勞保機關做為審核標準的每人次平均醫療費用來分析，則每人次平均醫療費用最高為公務人員眷屬保險的368元，其次為農保及退休人員眷屬保險的363元，再其次為勞保的350元及公保的343元，而自費病患每人次平均醫療費用為224元，至於每人次平均醫療費用最低的為榮民，僅有135元，造成偏低的原因和給付費用有直接的關係。至於採用公保機關的審核方法，可以明顯看出三所群醫中中心公勞農保病患的平均醫療費用，無論是急、慢性病或牙科都比自費病患高，當中，又以牙科差距最大。勞保機關的審核是以每人次平均醫療費用的多寡做標準，對於費用較高者，在審核後對所有處方箋採用固定百分比刪除，不容易對有問題的醫師或牙醫師產生制裁效果，反而容易引起彼此間的磨擦。建議採用公保機關的審核方法，將醫療費用分為牙科與醫科兩部份，其中醫科部份再分成急慢性病，則可以馬上針對各科收費過高的部份予以審核，並且急性病的每人次平均醫療費用的免審範圍和私人診所公平處理，相信必可消除不少開業醫師對群醫中心的反彈。
  In order to explore the medical cost in group practice centers we collected patients data in three centers from October 1, 1987 to March 31, 1988. Totally there were 44859 visits. They were grouped into three categories as dental, acute and chronic disease and the number of visits were 2727 (6.1%), 23624 (52.7%) and 18518 (41.3%) respectively. The medical cost per visit of dental disease was NT$549 which was much higher than the one of medical disease (NT$323). As to the chronic and acute disease, the medical cost per visit were NT$361 and NT$293 respectively. It is suggested to supervise the medical cost of dental disease in group practice centers. About the item of the insurance, the highest medical cost per visit was the patients with Government Official's Couple Insurance (NT$368), followed by the patients with Farmer Insurance or Retired Government Official's Couple Insurance (NT$363). The medical cost per visit were NT$355 and NT$343 in the patients with Labor Insurance and Government Official Insurance respectively. The medical cost was NT$224 in the self-reimbursement patients and one of the reasons is the lower percentage of chronic disease. The medical cost in the patients with Labor Insurance or Government Official Insurance was much higher than the one in self-reimbursement patients, not only in the category of dental disease, but also in the categories of acute and chronic disease. It is suggested that the billing system of insurance company should be based on both the medical cost per visit and the categories of acute, chronic and dental disease
• 175 - 183
• 10.6288/JNPHARC1991-10-0304-07

• Link 實務 Public Health Practice
• 三所群體醫療執業中心的成本分析Cost Analysis of Three Group Practice Centers
• 李世代、 謝維銓、 吳凱動
  Shyh-Dye Lee, Wei-Chuang Hsien, Kai-Shinn Wu
• 無
  Group Practice Center GPC ; Cost
• 本研究目的在透過成本會計分攤方法，估算三所群醫中心（平溪、雙溪、貢寮）75-76會計年度的醫療及保健成本。經成本分攤後，各項服務的單位成本如下：（一）門診診療：平溪，397元；雙溪，183元；貢寮，156元；（二）婦幼衛生服務：平溪，936元；雙溪，508元；貢寮，335元；（三）預防接種：平溪，158元；雙溪，105元；貢寮，57元；（四）家庭訪視：平溪，888元；雙溪，800元；貢寮，743元。此外，本研究亦發現：(1)群醫中心之營運收支，均有相當之盈餘（毛利）；但若將衛生所公務預算納入分攤後，則不一定會有盈餘；(2)診療成本中以藥品藥材所佔比率最高，分攤公務預算之後，人事費亦佔相當大之比率；(3)診療服務的非固定成本比率很高，甚至高過固定成本；而保健或公共衛生工作，則固定成本佔有極大的比率。
  The purpose of this study is to find the costs of three group practice centers (GPCs) through the apportionment of cost out-patient visit is NT$ 397 for Ping-Hsi, NT$ 183 for Shuang-Hsi, NT$ 156 for Kong-Liaw; (2) unit cost per maternal and child health service is NT$ 936 for Ping-Hsi, NT$508 for Shuang-Hsi, NT$335 for Kong-Liaw; (3) unit cost per vaccination is NT$ 158 for Ping-Hsi, NT$105 for Shuang-Hsi, NT$ 57 for Kong-Loiaw; and (4) unit cost per home visit if NT$888 for Ping-Hsi, NT$800 for Shuang-hsi, NT$ 743 for Kong-Liaw. Furthermore, the study found: (1) The balance of GPC is not necessarily favorable after the budget for a health station has been allocated to GPC. (2) Drug expenses are highest in the cost of GPCs, and personnel expenses are also high if the budget for a health station is allocated. (3) The proportion of non-fixed cost in put-patient service is very large. As for public health service, fixed cost plays the major role.
• 184 - 193
• 10.6288/JNPHARC1991-10-0304-08