16卷3期

• Link 綜論 Review Article
• 肝組織核染色體套數變化與肝細胞癌的關係Changes in Hepatic Chromosomal Ploidy and Hepatocellular Carcinoma
• 張照勤、陳建仁
  Chao-Chin Chang, Chien-Jen Chen
• 核染色體套數 ； 多倍套體化現象 ； 雙套染色體 ； 肝細胞癌
  chromosomal ploidy ; polyploidization, diploidy, hepatocellular carcinoma
• 在哺乳動物的肝組織中，含有一個相當重要的特色，即在正常的狀態之下，便會產生多倍套體的肝細胞存在於肝組織中，且因年齡增長而有多倍套體細胞比例增加的趨勢，即所謂的「年齡相關多倍套體化」現象，其被認為是肝臟為了自身保護作用而演化形成。動物研究進一步顯示，在化學致癌物的作用下，由癌前組織逐漸惡化為肝細胞癌的過程中，雙套染色體肝細胞比例會逐漸增加；此在人體研究自慢性肝炎轉為肝癌的進程裡，也有相同的結果發現。由於雙套染色體肝細胞比例的增加易於導致致癌基因的活化與抑癌基因功能的喪失，因此被認為與肝癌的發生有密切的關係。近來，更利用染色體含量的變化來診斷臨床上癌症病患的預後狀況與探討腫瘤的單株增生。人體肝癌的產生，大多是由病毒長期作用所引起，而且其產生是屬於多重因子的共同作用，與動物化學致癌作用迥異，因之本文乃對以上相關研究做一綜論，以俾了解染色體套數變化在致肝癌過程中所扮演的角色。
  In normal livers of mammals, hepatocytes proceed polyploidization which is thought to evolve for self-protection of livers. The polyploidization is age-dependent. Animal studies showed an increase in diploid proportion gradually from precancerous stage to hepatocellular carcinoma (HCC) induced by chemicals; similar findings were also observed in hepatocarcinogenesis of human studies. Because the increasing diploid proportion is inclined to activate oncogenes and lose tumor suppressor genes, it is believed to be related to the development of cancer. Changes of DNA content has been used in predicting the prognosis of patients affected with HCC and also in studies of clonal expansion of HCC. As most human HCC is related to hepatitis viral infection and multifactorial in origin, its ploidy changes may be different from chemical-induced HCC in animal models. This review summarizes the role of chromosomal ploidy changes during hepatocarcinogenesis.
• 185 - 197
• 10.6288/CJPH1997-16-03-01

• Link 原著 Original Article
• 金門縣婦女子宮頸防癌抹片檢查的影響因素Factors Related to Acceptance of Pap Test by Women in Kinmen
• 李翠鳳、郭旭崧、 陳錫中、陳天順、周碧瑟
  Tsuey-Feng Lee, Hsu-Sung Kuo, Hsi-Chung Chen, Tien-Shen Chen, Pesus Chou
• 子宮頸防癌抹片檢查 ； 知識 ； 態度與行為研究
  Pap test ; KAP knowledge, attitude and practice study
• 本研究根據1990年於金門縣針對30-64歲已婚婦女所作之調查加以分析研究，藉以了解影響金門地區已婚婦女抹片篩檢行為的因素。本研究根據金門1989年戶政資料，在全縣8541名30-64歲已婚婦女中，採系統抽樣法按1比7比例抽出1203名進行家訪問卷調查，實際完成990份，回收率達82.3%。本研究結果發現有81.7%婦女曾聽過子宮頸防癌抹片檢查，有62.1%曾作過抹片檢查，其中有定期受檢者49.0%；沒參加過抹片檢查的主要原因為：沒聽過抹片檢查，覺得抹片很可怕及不知道抹片時間地點。在聽過抹片檢查的764位婦女中，其社會人口學特徵中，居住地區、年齡、教育程度、先生職業等因素會影響婦女抹片行為。健康信念中，對子宮頸癌知識與態度越正確，篩檢行為越積極。婦科求診經驗中，曾去過婦產科及對醫護人員滿意度較高的婦女行為較積極。曾有人告知抹片過程及方法的婦女受檢率較高；消息來源以電視、報紙及親友告知為主，而消息來源為醫護人員者受檢率最高，同時社會支持越多，受檢率越高。抹片服務特性中，婦女是否知道抹片時間地點會影響抹片行為。影響婦女抹片行為的重要因素：子宮頸癌知識，與醫護人員熟悉程度，有無婦科症狀，是否有人告知抹片過程及方法，抹片時間地點及教育程度。
  In this study, data on married women living in Kinmen aged 30 to 64 were collected in order to assess factors related to the use of the Papanicolaou test (Pap test) in the Kinmen area. According to 1989 government records, there were 8541 married women aged 30 to 64 in Kinmen. Systematic sampling (1:7) was used to create a group of 1203 women to be interviewed in their homes. 990 completed the interview (response rate 82.3%). 81.7% of the 990 respondents had heard of the Pap test, 62.1% had undergone a Pap test at least once, and 49.0% had it as part of the regular physical examination.
• 198 - 210
• 10.6288/CJPH1997-16-03-02

• Link 原著 Original Article
• 柏列特原理在門診醫療之解析與運用Analysis and Application of Pareto Principle in Outpatient Service
• 陳志銘、韓揆
  Chih-Ming Chen, Kuen Han
• 柏列特原理；門診；單位價值對比值
  pareto principle ; ambulatory care ; relative unit value
• 柏列特原理指出「精寡粗多」的現象。本研究應用此原理來分析醫院門診產出，並建構一個衡量此精寡程度的指標：單位價值對比值(RUV, Relative Unit Value)，以做為管理決策之參考。研究材料為某中型醫院之「勞保門診醫療費用申報明細檔」，方法則以RUV值探討門診產出之診斷別和醫師別在「就醫人次」指標上之精寡粗多程度。由80/20原理之經驗，RUV值等於16；故本文取16做為「精寡粗多」與否的初步臨界值。結果發現，診斷別之RUV值皆大於16；也就是病人集中在少部份診斷的現象明顯；且分科的RUV值大於未分科，即科別是影響診斷別RUV值高低的重要因素。反之，醫師別分科與否的RUV值則無差異且皆小於16。換句話說，該樣本醫院，並沒有少部份醫師看大部份診次的現象，而分科與否並不影響結果。此RUV值理論模式尚可應用於其他層面，如醫院成本控制、醫院倉儲管理、醫療品質管制…等。至於是否決定以16作為RUV臨界值，可因事制宜。
  Pareto principle (80/20 rule) points out the phenomenon of ”vital few and trivial many”. The study applies this principle to analyze the outputs of ambulatory care and tries to generate an indicator: Relative Unit Value (RUV) to measure the concentration of ”vital few”, that can help the decision making of hospital management. Data was from the profile of outpatient claims for the Labor Insurance Payment in one middle-sized hospital. We studied the RUV of the visits on different diagnoses and different physicians, which were viewed as the output of ambulatory care. Due to the rule of ”eighty-twenty”, we set RUV equal to 16 as a primary standard. Results show that RUV of the visits on the diagnoses which are stratified by department are larger than non-stratified, and their values are also larger than 16. It means that a few diagnoses will include most diseases, and the stratification of department also playes an important role on the concentration of a few vital diagnoses. But it makes no difference that RUV of the visits on the physician. It means that phenomenon of a few physicians includes most of visits is not significant. RUV can also applied to many aspects as well, such as cost control, inventory management, and quality assurance.. etc. However, the setting of RUV standard value will depend on the characteristics of the event.
• 211 - 217
• 10.6288/CJPH1997-16-03-03

• Link 原著 Original Article
• 長期照護機構院民之病例組合研究Case-Mix Classification System of Residents in Long-Term Care Facilities
• 吳淑瓊、楊紅玉
  Shwu-Chong Wu, Hung-Yu Yang
• 長期照護機構 ； 資源耗用 ； 病例組合 ； 支付系統 ；
  long-term care facilities ; resource utilization ; case-mix ; payment system
• 本研究旨在發展長期照護機構院民的病例組合分類系統，研究資料來自五家養護中心720位院民，以美國MDS(Minimum Data Set)評估之院民身心狀況與服務需求為分類變項，並以碼錶登錄每位院民一天24小時內接受護理人員與護佐照護時間，及一星期內接受各類專業人員的特別處置時間，測量院民的資源耗用量，再利用PC-Group電腦軟體中的AID(Automatic Interactions Detection)進行院民資源耗用群歸組。結果發現，若以護理人員與護佐照護處置時間測量資源耗用，病例組合系統可將院民歸為12個不同資源耗用組，分組可解釋28.4%的資源耗用變異量，資源耗用最大組的平均資源耗用量為最小組的3.8倍；若以全部工作人員照護時間測量資源耗用，則可將院民分為9組，解釋25.4%資源耗用變異量，資源耗用最大組的耗用量為最小組的三倍左右。在資源耗用的歸類中，院民的身體功能、認知障礙、傷口治療、管灌餵食、疾病罹患、與急性症狀的有無等，均為重要分類變項。以上長期照護病人病例組合系統除可提拱制定長期照護支付標準的參考，並可幫助機構內部人力調派與品質保証等管理措施。
  Two case-mix classification systems for institutional long-term care were developed based on a sample of 720 residents in 5 long-term care facilities. MDS (Minimum Data Set) evaluation of residents' physical/mental status and care need were gathered, along with stopwatch measure of resource utilization including nursing staff care time over a 24-hour period and therapy staff time over a 1-week period. Using AID analysis, residents were classified into 12 groups that were homogeneous in their use of nursing resources. The classification explains 28.4% of the variation in nursing staff care time. The mean nursing resource use of groups spans a 3.8-fold range. If resource use was measured by total staff care time, a 9-group classification system was developed. It can explain 25.4% variance in total care time. The mean total resource use of groups spans a 3-fold range. Two variance systems have identified that physical functioning, cognitive impairment, skin ulcer or wound care, feeding tube, presence of chronic disease, and presence of acute episode are important variables in categorizing residents into different resource use groups. The classification system of long-term care patients can provide a reference for the design of long-term care payment system, staffing level determination, or quality assurance schemes.
• 218 - 230
• 10.6288/CJPH1997-16-03-04

• Link 原著 Original Article
• 愛滋病風險、醫師的臨床防護及照護意願Aids Risk, Physicians' Clinical Precautions and Willingness to Treat Aids Patients
• 丁志音、涂醒哲
  Chin-Yin Lew-Ting, Shiing-Jer Twu
• 愛滋病 ； 風險 ； 防護行為 ； 照護意願
  AIDS ; risk ; clinical precautions ; willingness to treat PWAs
• 風險已成為愛滋病防治與照護中的主流觀念。本研究旨在探討愛滋病相關風險對醫師的防護行為及照護意願的影響。研究資料得自一全國性的郵寄問卷調查，最終之研究樣本包括1702名年齡70歲以下之西醫師，回覆率為24.3%。本研究之主要核心變項為「風險特質」－即愛滋病相關風險，共包含三個層面：臨床或職業風險、愛滋病風險評量、以及自覺被感染風險。主要研究結果為：(1)自覺感染風險相當程度的受到臨床風險及愛滋病風險評量的影響。在醫院服務之醫師的臨床風險及自覺感染愛滋病之風險均高於開業醫師，且年齡愈輕者愈如是，(2)高達80.8%的醫師擔心自己在照護愛滋病患時受到感染，其和愛滋病風險評量及自覺被感染風險之相關較強，但與實際臨床風險的相關較弱，(3)無論就防護行為或照護意願而言，愛滋病風險評量皆為三個風險變項中最具影響力者，而影響力最弱者仍為臨床風險。因此，主觀的風險知覺對醫師的心理狀況及行為意向遠比客觀的實際臨床風險來得重要。為了舒緩醫師對愛滋病的恐慌並增強其照護意願，除加強?育及訓練以期能掌握相關的風險狀況之外，更應強調合宜的風險溝通，並能提供防護設備，鼓勵其採取必要的防護措施。
  Risk has emerged as a main concept in AIDS prevention, control, and providing care to those who were HIV-infected. This study concerns the impact of risk on the physicians' willingness to treat People with AIDS (PWAs) and adopting precautions in the course of AIDS clinical work. Data for this study came from a mailed survey of a national representative random sample of active physicians. A total of 1702 physicians participated in this study, which resulted in a response rate of 24.3%. The core construct of this study ”AIDS-related risk” is conceptualized into three aspects of risk characteristics: (1) clinical/occupational risk, (2) AIDS risk assessment, and (3) perceived risk of infection. The major findings are: (1) Clincial risk and AIDS risk assessment can predict a substantial proportion of variability of perceived risk of infection. Compared with physicans working in private clinics, hospital/medical center physicians were at a greater exposure of clinical risk and higher in perceived risk of infection, which is especially the case among younger physicians, (2) While as many as 80.8% physicians worried about contagion in providing care to PWAs, both AIDS risk assessment and percieved risk of infection, rather than clinical risk, had much stronger correlation with worry, and (3) Among three AIDS-related risk variables, AIDS risk assessment is the most powerful predictors of both willingness to provide care and precautions adoption, and clinical risk the least. The results suggest that subjective risk perception plays a much more important role than objective risk in translating worry/fear into behavioral intentions. To assure that our health care system manages HIV disease effectively, interventions need to bring about changes in physicians' perception of risk, and, even more importantly, their ability to undertake infection control measures against HIV transmission.
• 231 - 243
• 10.6288/CJPH1997-16-03-05

• Link 原著 Original Article
• 作業場所通風特性評估方法之研究Study of Methods for Evaluating Ventilation Characteristics in Work Places
• 劉德齡、王秋森
  De-Ling Liu, Chiu-Sen Wang
• 追蹤氣體技術 ； 平均空氣年齡 ； 通風特性
  average age of air ; tracer gas techniques ; ventilation characteristics
• 本研究主要目的在於以追蹤氣體技術建立一簡易、實用之通風測量方法，以期適用於使用整體換氣之作業場所其通風特性之測定與評估。通風為工業衛生中危害控制之一環，通風功能之良窳對現場工作人員之健康有相當重要的影響。本研究分別選擇在三種不同類型之作業場所：半導體業之清淨室、大樓辦公室與印刷廠中進行。利用脈衝注射法或濃度衰減法，在待測空間之空調入口內釋放追蹤氣體六氟化硫或二氧化碳，由擺設在作業場所中位於呼吸區高度、不同位置的紅外光吸收光譜儀－MIRAN或B&K IR，記錄該測量地點之追蹤氣體濃度變化與時間之關係。由此計算出局部通風率、平均空氣年齡等通風參數。 由現場測量之結果顯示：作業環境空調出、回風口的位置與形式，空氣之再循環情況、與熱源分別為影響上述測量地點通風特性之關鍵。氣流型態為置換式氣流的清淨室，在空間的不同位置測得之平均空氣年齡差異可達4倍之多，並有氣流短路現象。在空氣總供應率8.5hr^(-1)之大樓辦公室經濃度衰減法求得其有效通風率僅0.7hr^(-1)；室內空氣主要為再循環使用。在印刷廠中，當其重要熱源－印刷機組開始運轉後，使原接近空氣完全混合之氣流型態變為不均勻混合，其中一測點之局部通風率約降為印刷機組完全未啟動時1/7，顯示熱源所在之位置與強度對通風帶來負面作用。
  The primary objective of this study is to develop a practical method for evaluating ventilation parameters and investigating ventilation characteristics in work places equipped with a general ventilation system. Designed and operated properly, a ventilation system can be effective for hazards control. Three work places were selected for this study: a cleanroom, an office, and a printing factory. After a tracer gas (sulfur hexafluoride or carbon dioxide) was released into the air supply, its concentrations were measured at various locations by non-dispersive infrared photometers. The ventilation parameters, such as local ventilation rate and average age of air, were then calculated from the results obtained by tracer gas concentration decay method or pulse injection method. The results of field measurements indicate that the position and type of air inlets and outlets, the air recirculation rate, and the heat sources were the key factors influencing the ventilation characteristics. In the cleanroom studied, the air was found to be short-circuiting and the average age of air at one of the air outlets was about one-fourth of the highest value measured in the cleanroom, In the office studied, the total supply air rate was 8.5 hr^(-1), but the effective ventilation rate was only 0.7 hr^(-1) because most of the air was recirculated. In the printing factory studied, the airflow pattern was found to be incomplete mixing when the printing machines (which act as heat sources) were in operation. Furthermore, one local ventilation rate was reduced to one-seventh of the rate when there were no significant heat sources. Clearly, the heat sources have negative effects on ventilation performance.
• 244 - 257
• 10.6288/CJPH1997-16-03-06

• Link 實務 Public Health Practice
• 從二十一世紀議程看台灣的毒管政策應走之方向Proposed Amendment of Policy of Toxic Substance Control in Taiwan
• 王榮德、黃耀輝
  Jung-Der Wang, Yaw-Huei Hwang
• 毒性物質 ； 管理政策 ； 二十一世紀議程
  toxic substance ; control policy ; agenda 21
• 毒性物質如果未受到適當的管制而流佈於環境中，經環境蓄積、生物濃縮、生物轉化等方式後，會導致污染環境，並危害人體健康。目前，國內使用及製造之毒性物質甚多，因而有關毒性物質管理工作是現今環境保護的重點工作之一。以下即是針對毒性化學物質管理政策與執行所做的具體建議，以期符合二十一世紀議程的要求： 1．積極加強毒化物管理人才之培育，傳播相關資訊給一般大眾及勞工，編訂毒化物管理人才訓練課程與?材，做出系列毒管錄影帶，以?育一般大眾及勞工。 2．積極推動新的「毒性化學物質管理法」在立法院修法通過，檢討此法與其他相關法規間之配合與衝突性。 3．推動毒化物清冊與毒化物資訊中心之建立，建立毒管績效相關指標，以長期評估執法之成效。 4．協調統一化學物之分類及標示：定期舉辦協調會，責成各相關部會取得國際最新資料，訂定統一之標示及分類法與分類碼。 5．在產業界進行、並提昇風險評估與降低風險之相關技術。 6．建立促進產業推動污染預防與降低風險之經濟誘因制度，政府負責部門應慎重採取的方法包括：保證金制度、課徵產品費、正面的無形誘因、環境風險保險制度，以及生產者責任制、毒物釋放量逐年減少、告知民眾、危害預防及應變計劃與演練等。
  Toxic substances which are under not adequately controlled would be widely distributed and then, through accumulation, biological concentration and transformation, resulted in causing environmental pollution and adverse health effects on human being. Currently, a wide variety of toxic substances are used and manufactured in Taiwan, and, therefore, regulation and management of these materials have become one of the most important issues on environmental protection. Recommendations are made to enhance the policy and implementation plan of toxic substances control and meet the requirement of Agenda 21. (1) Reinforce the training of management personnel for toxic substances control, and disseminate pertinent information to the public and workers. Edit curriculum and education material for the training of toxic substances control personnel, and produce video series of toxic substance control programs to educate the general public and workers. (2) Propel the Legislative Yuan to pass the revised 'Toxic Substance Control Act', and scrutinize the compliance and conflict between this act and other relevant regulations. (3) Establish substances registry and information center. Develop performance indicators for toxic substance control to evaluate the long term effectiveness of enforcement. (4) Harmonize the classification and labeling of chemicals: Hold regular coordination meetings among related ministries to collect most updated internationally information, and harmonize the labeling, classification and codes. (5) Promote and execute risk assessment and risk reduction technology among industries. (6) Establish economic incentives for industries to prevent pollution and reduce risk. Actions including performance bond, product fee, positive invisible incentive, environmental risk insurance, producer responsibility, reduction of toxic substance release, community right to know, risk prevention, and contingency plan & practice should be seriously taken by the responsible governmental agency laterly.
• 258 - 272
• 10.6288/CJPH1997-16-03-07

• Link 研究紀要 Research Brief
• 台灣地區死因統計準確度評估(Ⅱ)：死亡證明書高頻率開具者特徵分析Evaluating the Validity of Cause-Of-Death Statistics in Taiwan (?): Characteristics of High Frequency Death Certificates Certifiers
• 呂宗學、 石台平、賴華山、李麗雪、李孟智、周明智
  Tsung-Hsueh Lu, Tai-Ping Shih, Hwa-Shan Lai, Li-Shu Lee, Meng-Chih Lee, Ming-Chih Chou
• 死亡證明書 ； 死因 ； 生命統計 ； 醫師行為
  death certificate ; cause-of-death ; vital statistics ; physician behavior
• 本研究分析死亡證明書高頻率開具者特徵及死因診斷品質，提供改善死因統計品質計畫擬定參考。本研究分析民國83年台灣地區的死亡證明書111,927張。研究結果發現一年開具一百張以上者共110位，佔總開具人數0.67%，但所開具的死亡診斷書總張數卻有28,796張，佔總張數22.47%，這些少數高頻率開具者對台灣死因統計品質有重要影響。高頻率開具者特徵為：年紀較長、較高比率為甄試特考出身、較多為一般科且大多數在非?學醫院及診所服務。死因診斷形式錯誤率，高頻率開具者較高。之所以會出現少數超高頻率開具者，可能是因為台灣特殊的「行政相驗」制度所造成，本文也針對行政相驗的可能缺失提出檢討與改進建議。
  This study describes the characteristics of high-frequency death certificate certifiers and the quality of their cause-of-death diagnoses in order to provide information for designing a program to improve the quality of cause-of-death statistics. In Taiwan, there were 111,927 death certificates issued in 1994 and the frequency of death certificates issued by one certifier a year was highly skewed. One hundred and ten doctors issued more than 100 death certificates a year. They comprised 0.67% of all certifiers, but the death certificates issued by them accounted for 22.47% of all death certificates. These certifiers had great influence on the quality of cause-of-death statistics in Taiwan. Most of these high frequency certifiers were: older in age, not graduated from medical schools, general practitioners and served in non-teaching hospitals or clinics. The percentage of formative errors on cause-of-death diagnoses was higher for high-frequency certifiers as compared to low-frequency certifiers. The special ”administrative certification” process in Taiwan is the reason for the large number of high-frequency death certifiers. The defects of this system are discussed and some proposals for improvements are raised in this study.
• 273 - 279
• 10.6288/CJPH1997-16-03-08