臺灣博碩士論文加值系統

目標：本研究共有四個研究目的：一、調查結核病人治療前死亡及治療期間死亡之危險因子；二、調查「因結核病而死」和「非因結核病而死」相關因子；三、估算結核病人復發發生率及相關危險因子；和四、評估結核病及結核病藥物對憂鬱症發生之影響。
研究對象：這一研究之對象來源包括2005年至2010年台北市結核病人通報資料及台灣健保資料庫。
結果:這一研究發現台北市結核病人76.8%治療成功、5.4% 死於未開始治療前、 9.0% 死於開始治療8周內及 8.8%死於開始治療8周後。控制其他干擾因素後，年紀65歲以上及男性會有較高的風險死於未開始治療前、開始治療8周內或8周後；與未受教育個案相比，肺結核個案本身教育程度若是高中、大學或以上者，會有較低風險死於未開始治療前、開始治療8周內或8周後；肺結核個案本身若是失業，會有較高的風險死於開始治療8周內或8周後；肺結核個案若胸部X光有開洞病兆或痰液抹片呈現陽性，會有較低的風險死於未開始治療前。這一研究亦發現結核個案若參加都治治療會降低55%因結核病而死亡；這一研究亦看到結核個案若一天抽菸10根以上者，會增加2倍結核病復發；這一研究亦發現結核病會增加1.7倍憂鬱症發生之風險；同時結核病人若有使用Ethambutol 60 天以上者，會增加2.5倍憂鬱症發生之風險，同時使用Ethambutol之劑量與憂鬱症發生之風險呈正向線性關係。
結論：為了有效改善結核病人瘉後，臨床醫師針對結核病診斷需維持高度警覺，尤其針對年齡≥65以上、男性或低社經地位結核個案，需盡快提供必要的治療。同時所有結核病人應安排都治治療以降低「因結核病而死」之風險；有效戒菸措施亦應納入結核病防治策略中；若個案被診斷結核病後，此些個案應被仔細追蹤評估憂鬱症發生之情形，尤其針對有使用Ethambutol60天以上之個案。

OBJECTIVE: This study had four aims: to identify prognostic factors associated with mortality before start of and during tuberculosis (TB) treatment among adult TB patients in 2005–2010 (Aim 1); to investigate factors associated with TB-specific and non-TB-specific mortality, respectively, among adult TB patients during the period 2006–2010 (Aim 2); to estimate the incidence of TB recurrence and analyzed associated risk factors (with particular emphasis on smoking) among adults who had successfully completed TB treatment in Taipei, Taiwan from 2005 through 2010 (Aim 3); To determine the effects of pulmonary TB (PTB) and anti-TB drugs on the risk of incident depressive disorder using a nationwide population-based cohort study in Taiwan (Aim 4).
STUDY POPULATION: This study included adult TB patients from Taipei TB surveillance dataset in 2005-2010 (Aim 1 through Aim 3) and TB cases from the Taiwan National Health Insurance Research Database (NHIRD) in 2000-2010 (Aim 4).
RESULTS: This study found that 76.8% of TB patients in Taipei were successfully treated, 5.4% died before start of treatment, 9.0% died within 8 weeks of treatment initiation, and 8.8% died later than 8 weeks after treatment initiation. After controlling for potential confounders, age ≥65 years and male sex were associated with higher risks of death at all investigated time periods. A high school education or higher decreased the risk of death before start of and during treatment, while unemployment increased the risk of mortality during treatment. Cavity on chest X-ray and positivity for acid-fast bacilli were associated with lower risk of mortality before start of treatment. This study also showed that the odds ratio for TB-specific mortality was 0.45 (95% CI: 0.30–0.69) among patients treated with directly-observed treatment (DOT) as compared with those on self-administered treatment. Moreover, the risk of TB recurrence among subjects who smoked more than 10 cigarettes a day was double that of never/former smokers after controlling for other variables. This study also found that TB was an independent risk factor of incident depressive disorder (adjusted HR, 1.74). The risk of incident depressive disorder was significantly higher (adjusted HR, 2.54) in patients with TB who received more than 60 defined daily doses (DDDs) of ethambutol, and the effect was dose-dependent.
CONCLUSION: To lower mortality among TB patients, it is imperative for clinicians to maintain high alertness to TB and to provide more intensive care early, especially for the elderly, men, and people with lower socioeconomic status (e.g. unemployed and less educated). DOT should be given to all TB patients to further reduce TB-specific mortality and effective measures of smoking cessation should be incorporated into TB control programs to reduce the risk of recurrence. Depressive disorder should be sought in patients following tuberculosis, particular in those with an ethambutol dose of more than 60 DDDs.

Content
中文摘要 (ABSTRACT) 1
ABSTRACT 3
INTRODUCTION 5
AIMS OF THE STUDY 9
MATERIALS AND METHODS 10
STUDY POPULATION AND DATA SOURCE (AIM 1 THROUGH AIM 3) 10
STUDY POPULATION AND DATA SOURCE (AIM 4) 11
OUTCOME VARIABLES 12
EXPLANATORY VARIABLES 14
STATISTICAL ANALYSIS 16
RESULTS 18
PROGNOSTIC FACTORS ASSOCIATED WITH MORTALITY BEFORE START OF AND DURING TUBERCULOSIS TREATMENT 18
FACTORS ASSOCIATED WITH TB-SPECIFIC AND NON-TB-SPECIFIC MORTALITY 25
FACTORS ASSOCIATED WITH TB RECURRENCE 34
ASSOCIATION OF PULMONARY TUBERCULOSIS WITH INCIDENT DEPRESSIVE DISORDER 45
DISCUSSION 60
LIMITATIONS 74
CONCLUSION 76
ACKNOWLEDGEMENTS 78
REFERENCES 79

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