15卷1期

• Link 綜論 Review Article
• 皮膚砷癌之流行病學特徵與危險因子Epidemiologic Characteristics and Risk Factors of Arsenic-Induced Skin Cancer
• 薛玉梅、陳建仁
  Yu-Mei Hsueh, Chien-Jeu Chen
• 皮膚砷癌 ； 流行病學 ； 危險因子
  Arsenic-Induced Skin Cancer ; Epidemiology ; Risk Factor
• 本文係綜論皮膚砷癌的流行病學特做與危險因子。砷引起的皮膚癌屬於非黑色素瘤皮膚癌。一般的非黑色素瘤皮膚癌常見於白種人，男性比女性有較高的發生率。它好發於臉、頭及頸部，軀幹及上肢是次常發部位；而且隨日曬程度增加。紫外線輻射、化學物質、游離輻射線、免疫因素、宿主因素為其主要之危險因子。砷是一種類金屬，往往經由礦脈、銅精煉廠、工業和農業用途，造成環境的污染。引起健康危害的砷主要是無機砷，它會引起胃腸道障礙、心臟血管疾病、神經病變、肝腎障礙、皮膚病變和癌症。砷已被公認為人類之皮膚和肺的致癌物。砷引起皮膚癌的主要暴露途逕為藥物，環境和職業暴露。皮膚砷癌的發生部位大多為非日曬部位，即手掌、腳蹠、肢端和軀幹，且屬全身多發性的表皮癌化病變。臺灣西南沿海烏腳病盛行地區的皮膚癌盛行率及死亡率，與深井水含砷濃度呈劑量效應關係。吾人研究發現烏腳病高盛行地區的皮膚癌盛行率，與慢性砷暴露指標，包括烏腳病盛行地區居住年數、飲用深井水年數、飲用水平均砷濃度、和累積砷暴露等，均呈現顯著的劑量效應關係。皮膚砷癌盛行率也與從事鹽田工作、B型肝炎帶原且肝功能不良、食用蕃薯簽年數偏高有顯著相關。人體內的無機砷代謝能力，尿液砷物種分佈，血清微量營養素濃度，以及免疫能力與皮膚癌的相關性，尚待進一步証實。皮膚病變可作為與機砷長期暴露的生物指標，過去在烏腳病盛行地區的研究指出，皮膚癌和內臟癌的標準死亡比與累積死亡率，都比臺灣地區一般人口顯著偏高。砷引起皮膚癌的機轉，以及皮膚癌與內臟癌之間的關係，均是值得探討的主題。
  Research on the epidemiologic characteristics and risk factors of arsenic-induced skin cancer were reviewed in detail. Arsenic-induced skin cancers are nonmelanoma skin cancers. Nonmelanoma skin cancers are much more common in white than in black or other dark-skinned populations. The incidence of nonmelanoma skin cancer is greater in males than in females. It occurs mostly on the face, head and neck, while the trunk and upper extremities are the next most common sites. The risk of nonmelanoma skin cancer is asscciated with the sunlight exposure in a dose-response relationship. Ultraviolet radiation, chemicals, ionizing radiation, immunologic and other host factors are risk factors for nonmelanoma skin cancer. Arsenic is a metalloid element, contaminating the environment through leaching from mineral ores, copper smelting, and other industrial and agricultural sources. Inorganic arsenic is much more toxic than organic arsenic compounds. It induces gastrointestinal disturbance, cardiovascular diseases, neurological disorders, liver and kidney damage, skin lesions and cancers. Inorganic arsenic has been documented as a human carcinogen of the skin and lung. Exposure to inorganic arsenic from medicinal, environmental and occupational sources has been found to be associated with the development of skin cancer. In contrast with nonmelanoma cancers of other etiologies, arsenic-induced skin cancers occur on every part of the body, especially marked in areas unexposed to sunlight, such as the palms, soles, extremities and trunk. They are multifocal and randomly distributed epidermal carcinoma lesions. A dose-response relationship between the prevalence and mortality of skin cancer and the arsenic concentration of artesian well water has been well documented in a black-foot disease endemic area on the southwest coast of Taiwan. A significant dose-response relation has recently been reported between skin cancer prevalence and chronic arsenic exposure, indexed by duration of living in the endemic area, duration of consuming high-arsenic contaminated artesian well water, average arsenic in artesian well water and cumulative arsenic exposure. Salt field working, chronic HBsAg carrier status with liver dysfunction, and high consumption of dried sweet potatoes have been found to be significantly associated with an increased prevalence of arsenic-induced skin cancer in those living in the blackfoot disease endemic area. Arsenic metabolism capacity, distribution of urinary arsenic species, serum level of micronutrients and immunologic profiles need to be explored for their associations with arsenic-induced skin cancer. Skin cancer has been considered as a biological marker for chronic inorganic arsenic exposure. Both standardized mortality ratio and cumulative mortality of skin cancer and various internal cancers have been reported to be significantly higher among residents in the blackfoot disease endemic area than in the general population in Taiwan. The mechanism of arsenic-induced skin cancer as well as the association between skin cancer and internal cancers deserve further investigation.
• 1-26
• 10.6288/CJPH1996-15-01-01

• Link 原著 Original Article
• 1983年至1993年間台北地區流行性感冒病毒之病毒株分佈狀況Influenza Virus Strains Isolated from 1983 to 1993 in Taipei
• 曾仁谷、陳豪勇、洪其璧
  Ren-Ku Tseng, Hour-Young Chen, Chi-Byi Horng
• 流行性感冒 ； 台北 ； 流行病學 ； 再感染 ； 抗原性飄變
  influenza ; Taipei ; epidemiology ; reinfection ; antigenic drift
• 為瞭解流行性感冒病毒感染在台北地區的流行狀況，由1983年至1993年共採得咽喉部檢體3,112件，分離出158株(51%)流行性感冒病毒，其中74株(46.8%)為A型，58株(36.7%)為B型。依分離病毒之狀況雄到在各月份均可能有流行性感冒感染的流行，A/H1N1在四、五月而A/H3N2和B型在寒冷的12月和元月有較多的病毒被分離出來。A/H1N1、A/H3N2和B型三種流行性感冒病毒，皆有重複流行的跡象。本實驗室分離出之流行性感冒病毒株，近八成是由12歲以下小孩分離出來。流行性感冒流行期間，病毒分離率為45.5%。A/Taiwan/1/86(H1N1)係於1986年四月分離發現，已成為世界衛生組織分離流行性感冒病毒的標準試劑(CDC reagent kit)，迄今已8年了(1986-93)；另外A/Beijing/32/92(H3N2)係從北京市1-31'92的檢體分離出，本所12-16'91的檢體被鑑定為A/Beijing/32/92-like；1990年元月3日的檢體，被鑑定為B/Panama/45/90-like，因送檢較緩而此兩株未登列於CDC reagent kit中。
  In order to identify the influenza virus strains in Taipei, throat-swab specimens of 3,112 upper respiratory infection patients were collected from 1983 to 1993. The influenza virus was detected in 158 specimens; among them, 74 isolates (46.8%) were identified as influenza virus type A while 58 isolates (36.7%) were type B. The predominant strain in Taipei was type A (A/H1N1) in April and May, whereas type A (A/H3N2) and type B infections were much more common in the cold season of the year, namely from December to January. Around 80% of the isolates identified in this laboratory were from children under 12. During the epidemic of influenza virus infection, the isolation rate of the virus was about 45.5% during the epidemic season. Re-infections of all 3 types of influenza virus are quite common in Taipei. Strain A/Taiwan/1/86 (H1N1) used as a standard strain for the CDC reagent kit was first isolated by this laboratory April 1986. We also isolated a new strain on December 16, 1991 but it was later named Al Beijing/32/92-like, only because our sample arrived at CDC two days later than that of the original, which was first isolated on January 31, 1992 in Beijing. Prior to the identification of B/Panama/45/90, we isolated a strain similar to B/Panama/45/90 on January 3, 1990. However, again owing to delay in shipping of the isolated viruses to the CDC for confirmation. The two new isolates miss the chance to be listed as standard strains for the CDC reagent kit.
• 27 - 39
• 10.6288/CJPH1996-15-01-02

• Link 原著 Original Article
• 人體汗中碘分光光度儀分析法研究Determination of Iodine in Human Sweat by Spectrophotometry
• 毛義方、陳美蓮、林宜長、藍忠孚
  Yi-Chang Lin
• 碘濃度測定 ； 人體汗液
  total iodine determination ; sweat
• 本研究是建立使用分光光度儀測量人體汗液中碘含量之方法。將汗液樣本使用超音波振碎機使汗液均質化，然後使用強酸加入汗液中，使各類碘化合物轉化成碘酸物(iodate)，然後以此碘酸物催化As及Ce之氧化還原反應發生之呈色作為汗液中碘含量之測定依據。 結果顯示，本研究發展之方法對汗液中含碘量可作適當之定量，其準確度介於105.6~110.2%，其精確度CV值為3.4~5.7%，測定範圍為2~10ng/mL，利用本法取10名自願者之汗液樣本共40個，測得其汗液中含碘量，平均值為36.6±6.7μg/L。此研究提供了測量體液中含碘量的一個簡單、精確及可行之測定方法，可應用於流行病學及生理學上之研究。
  A spectrophotometric method for the determination of trace quantities of iodine in human sweat has been developed. The samples were completely homogenized by ultrasonication. Various forms of iodine in sweat were converted into iodate by acid digestion. The converted iodate then acted as a catalyst for the reduction reaction of Ce (?) in the presence of As (?) to develop color change for colorimetric analysis. The accuracy and precision of this method were tested with the spike method. From the experimental results, this method has been proved to be accurate enough for the determination of total iodine concentration in human sweat samples ranging from 2 to 10 ng/mL. A total of 40 sweat samples of 10 volunteers were examined, and the average concentration of iodine was found to be 36.6±6.7 µg/L. These results suggest that this method is a simple, reliable, feasible and sensitive method for the determination of iodine concentration in human body fluids.
• 40 - 46
• 10.6288/CJPH1996-15-01-03

• Link 原著 Original Article
• 全民健康保險論病例計酬制審核模式之研究Establishment of Case Payment Review Model under NHI
• 莊逸洲、吳明彥
  Yi-Chou Chuang, Ming-Yen Wu
• 前膽性付費制度 ； 診斷關係群 ； 論病例計酬制 ； 基本治療程序要求 ； 電腦化
  PPS Prospective Payment System ; DRGs Diagnosis Related Groups ; Case Payment ; Minimum Requirements ; Computerization
• 全民健康保險已於民國八十四年三月一日實施，依據過去勞工保險醫療給付所須審查之資料量來推估，全民健保之資料量門診每年至少有九億三仟多萬項，而住院每年亦有二千六百多萬項。面對如此龐大之資料量，將來審查工作勢必要透過資訊電腦化，建立審查標準，利用媒體申報向電腦自動核對，符合標準者即予核付，超出標準異常案例，再以人工審核，利用差異分析及異常管理之理念、工作簡化之制度設計，達到低成本高效率、確保醫療品質、簡化行政手續及提高給付時效等目標。 全民健康保險住院支付制度未來將採用DRGs，在國內版DRGs尚未建立前，為長遠之計，而有初期採用論量計酬(FFS)及論病例計酬(Case Payment)之混合制，再過渡至國內版DRGS。 DRGs之推動最被垢病的就是醫療品質無法確保，因此建立一套公平、公正、及公開之合理審查制度，以確保醫療品質，同時簡化行政手續、迅速合理支付醫療費用及節省行政成本，實為當務之急。 本研究針對住院部份即將實施論病例計酬，為確保醫療品質及不影響病人醫療的個別性下，由長庚紀念醫院各相關專科概訂並經各專科醫學會審查，已完成一般外科等十專科之腹股溝疝氣等廿八項疾病中英文對照之『基本治療程序要求』，以建立一套PPS制度下之醫療審查標準模式，可據以參考推廣至未來全部DRGs標準。茲建議全民健保優先由這廿八種疾病試辦並繼續向其他醫學中心及各專科醫學會合作，擴大論病例計酬之實施範圍。但在訂定論病例計酬標準時，必須考慮各不同等級醫院之平均疾病嚴重度差異，以建立人平合理之醫療給付制度。最後本研究針對相關審核模式及電腦流程提出建議。
  National Health Insurance (NHI) will be implemented on March 1, 1995. The estimate annual number of claim items reviewed under NHI will amount to at least 930 million for outpatient and 26 million for inpatient respectively. The only way to process those data efficiently is to set up standards for review, and to identify abnormal cases for manual review throughout the computer analysis. Finally, the objectives of NHI claim review system are quality assurance, process simplification, shortened reimbursement time by the design of simplification & the management of outliners. With respect to the case payment which will be adopted in inpatient reimbursement, 28 minimum requirements which are written in English & Chinese, based on diagnosis, have been completed. These minimum requirements were spelled out by the related departments of Chang Gung Memorial Hospital and reviewed by different associations of specialties in an effort to establish a peer review model under PPS or under DRGs in the future. These 28 cases are highly recommended to be implemented under Case Payment, and more minimum requirements should be completed by the cooperation of medical centers and specialty associations. In addition, the average variation of severity of illness in different levels of hospitals must be taken into consideration when setting up the reimbursement for case payment in order to pursue a fair & reasonable payment system. Finally, the related models of peer review and computerization process are also presented here.
• 47 - 60
• 10.6288/CJPH1996-15-01-04

• Link 原著 Original Article
• 捐血中心最佳生產模式及其軟體之建立Optimal Production Decision Support System for Taipei Blood Center
• 蘇喜、游張松、張銀益
  Syi Su, Chang-Sung Yu, Yin-Yih Chang
• 血液生產函數 ； 血液生產模式 ； 血液生產管理資訊系統 ； 全血／成分血
  Blood Production Function ; Blood Production Model ; Decision Support System ; Whole Blood/Component Blood
• 本研究為釐清捐血中心血品生產製程，導出血品及其製程之關係圖，並提出募血及其製程組合的“最佳生產製程規劃模式”。在各血品生產限制下，求取最佳生產製程組合，即以最低採血及製程成本來滿足各成分血需求。進一步應用線性規劃方法提出精簡快速的演算法，並以此演算法為依據，建立血品決策支援系統的雛形系統，稱為台北捐血中心血品製程規劃系統。
  This study was designed to elaborate production processes performed currently in Taipei Blood Center (TBC) and to coordinate the input material and output (whole blood and different type of blood component) relationship, thus so called production functions could be developed. Twenty-four production functions and thirteen constraints were clearly defined, and the decision support system optimal production software, that utilized linear programming method written in C language was established. The software was user oriented, once the daily required amount, inventory, safe and obsolescent level of whole blood, and each blood component were given, the selected processes and operation frequencies of production functions that must be triggered to meet demand at lowest possible cost could shown. TBC can then allocate manpower and arrange its work schedule accordingly.
• 61 - 79
• 10.6288/CJPH1996-15-01-05

• Link 原著 Original Article
• 醫院對急性白血病人保護隔離之成本效益研究A Cost Effectiveness Study of Protection for Leukemia Patients
• 星雙鈺、金春華、許惠媚、趙秀雄
  Nelson Hsing, Chuin-Hwa Chin, Hui-Mei Shu, Shiu-Hsiung Chao
• 存活分析 ； 保護隔離 ； 成本效益 ； 醫務管理
  survival analysis ; protective precaution ; cost effectiveness ; hospital administration
• 無
  Infection is the primary cause of death in acute leukemia patients. For years, hospitals have been practicing protective precautions to prevent patients from being infected. However, there is no consensus as to what protective precaution measures should be provided. One school of thought is that more frequent rounds should be made to patients, and preventive treatment given in time. This study was designed to explore the cost-effectiveness of protective precaution measures for acute leukemia patients. We have defined effectiveness as overall infection rate, the time interval between chemotherapy and the onset of first infection and the number of times infection occured. The result showed complete protective precaution measures cost NT $23,000 more than simple precaution measures for each episode (p<0.001), while the comparisons of effectiveness did not show statistical significance. Through survival analysis, we found that complete protective precaution may delay the onset of infection for 2 to 3 days longer than simple precaution. Nevertheless, there was no difference in the total number of infections between the two groups, indicating rigid protective precaution may not be as effective as we thought in terms of reducing the chance of patients being infected. Although this study does not show what effect different chemotherapy dosages have on the chance of infection, we feel that future research may demonstrate a relationship. Whether delay of infection has an impact on patient mortality remains an interesting question and is suggested for further study.
• 80 - 90
• 10.6288/CJPH1996-15-01-06

• Link 原著 Original Article
• 門診高度使用者之特性：以大溪鎮群醫中心門診病人為例Characteristics of Frequent Users of Clinic Service: A Case Study of Ambulatory Patients at Da-Xi Group Practice Center
• 許志成、季瑋珠
  Chih-Cheng Hsu, Wei-Chu Chie
• 群醫中心 ； 高度使用者
  Group Practice Center ; frequent user
• 為探討群醫中心門診高度使用者之特性，本研究選取大溪鎮衛生所79年10月至80年4月間的門診病人為對象，進行問卷訪視調查。本研究將月平均就診頻率為研究族群前5%之病人定義為高度使用組，共313人；並且自其餘門診病人中隨機抽取246人作為對照，稱之正常使用組。本研究以對數迴歸分析探討諸自變項對於高度使用門診的影響程度。研究結果發現：(1)年齡愈高者使用門診的機會愈大，大於65歲者成為高度使用組的可能性為小於40歲者的5.19倍；(2)在能力因素方面，有使康保險者成為高度使用組的可能性為沒有健康保險者的3.82倍；(3)在需要因素方面，罹患慢性病與自覺健康不佳皆為高度使用門診的原因，其勝算比分別為3.25與3.57；(4)社會支持功能不佳者成為高度使用組的可能性為社會支持功能良好者的2.11倍。根據研究結果得知，「需要因素」為高度使用門診最重要的因素；而健康保險所誘發的就診率增加，則有持進一步探討其適當性。
  This study was designed to examine the characteristics of frequent users at a group practice center (GPC). Patients who had visited Da-Xi GPC from May 1990 to March 1991 were chosen as the study population. Subjects were divided into two groups, the frequent user group and the control group. The frequent user group was comprised of 313 persons whose visiting frequency was in the top 5% among all registered patients. The control group consisted of 246 persons randomly sampled from the remainder. A questionnaire was employed for data collection and logistic regression was used for data analysis. The results show that: (1) The liklihood of becoming a frequent user for patients older than 65 years of age was 5.19 times that of patients younger than 40. (2) Insured patients were 3.82 times more likely to be frequent users. (3) Regarding need, chronic disease and poor health perception were both associated with frequent use with an odds ratio of 3.25 and 3.57, respectively. (4) Those who were poorly socially supported were 2.11 times as likely to become frequent users as those who were well socially supported. These results indicated the need factor is the most important causal factor in frequent health service utilization. The higher visiting frequency associated with insurance deserves further study.
• 91 - 96
• 10.6288/CJPH1996-15-01-07

• Link 原著 Original Article
• 南部某榮民安養之家住家榮民健康狀況調查A Survey of the Residents' Health Status at a Veteran's Home in South Taiwan
• 杜明勳
  Ming-Shium Tu
• 健康習慣 ； 健康狀況 ； 榮民安養之家
  Health habits ; Health status ; Veteran's home
• 為瞭解本院支援醫療作業之榮民安養之家住民之健康狀況，是以從事本調查，本探討之目的有：1．明白該社區內活動住民之健康習慣如何；2．其身體健康情況如何；3．其智能心理健康狀況如何。 自83年3月至9月間，對南部某榮家內登記之所有住家榮民942人施行調查，去除日常生活無法自行活動及配合調查之對象如癱瘓、聾啞及大陸定居等，共收集713個有效個案，調查其基本資料、健康習慣、身體狀況、及智能心理健康評估等。 結果顯示本調查之人口特徵為：平均年齡72.9±4.3(60.0-93.0)歲，單身男性為主，平均受教育年限3.9±3.8(0-16.0)，只有2%的人有子女照顧，48%的人在榮家種沒有要好的朋友。61%的人抽煙且大部份人煙量在一天一包左右，其煙齡大多超過30年以上，半數以上人每天運動時間不到一個小時。73%人最佳視力不超過0.1（閱讀書報有困難），72.7%人有聽力障礙，54%人無法咬食硬食，73%人現在因為生病正在接受藥物治療中，18.4%人關節疼痛而影響其日常起居活動，18%人三個月內曾經頭暈，3%的人三個月內曾經跌倒；26.5%人身體平衡有若干困難，70%人步態有或多或少的問題，10.8%的人日常活動量表顯示若干程度的依賴，18.6%的人工具性活動量表有部份依賴；60.9%人。血壓大於140/90毫米汞柱，15.1%人口懷疑有糖尿病；44.3%人懷疑有失智症；35%人有憂鬱傾向。
  The health habits and general needs for medical services of residents at a veterans home in South Taiwan were investigated. The purposes of this study were to explore the health habits of the residents of the veterans home, their general physical health, and their mental-psychological health status. During the 6 month period from March 1994 to September 1994, we investigated all the 942 residents of the veterans home. Those who were bed-ridden, deaf or mute, or travel-ling in Mainland China, were excluded from the study, due to poor adherence. The final study group consisted of 713 individuals. The mean age of residents age was 72.9±4.3 years old (range, 60-93), all were male, and most of them living alone. Their mean educational level was 3.9±3.8 (0-16) years. Only 2% had descendants to take care of them. Forty- eight percent of them had no close friends in the community. Sixty-one percent smoked, with an average consumption of one pack per day, and most had a smoking history of more than 30 years. More than half of them exercised less than one hour a day. Seventy-three percent had their best visual acuity not better than 0.1, making reading difficult. Most (72%) had somewhat impaired hearing. Fifty-four perceat could not bite hard foods, Most (73%) were on drugs because of illness of the time the study was conducted. Some (18.4%) had joint troubles that disturbed their daily activities. Eighteen percent had experienced dizziness or vertigo during the past 3 months, and 3% had experienced falls during the same period; About one-quarter (26.5%) had some problems with balance, and 70% had gait problems. Ten point eight percent revealed some dependence in ADL, and eighteen point six percent needed help in IADL. Sixty point nine percent had blood pressure higher than 140/90 mmHg and 15.1% were suspected of having diabetes mellitus. Forty-four point three percent were suspected of having dementia according to the Chinese version of the MMSE, and 35% were suspected of having depressive tendency by the Yersavage Geriatric Depression Scale.
• 97 - 107
• 10.6288/CJPH1996-15-01-08