臺灣博碩士論文加值系統

背景：過去台灣地區較少針對第2型糖尿病患者架構良好的社區性膽結石篩檢，本研究即在金門地區進行第2型糖尿病膽結石之社區性追蹤研究，評估其盛行率、發生率、及相關危險因子。
目的：本社區性研究之目的包括：
1. 估計第2型糖尿病患者其膽結石盛行率及其相關因子。
2. 經由一年之追蹤，估計第2型糖尿病患者其膽結石發生率及其危險因子。
3. 探討第2型糖尿病患者其血清胰島素、胰島素抗性、及�珩茩M功能與膽結石之間的相關。
方法：研究對象為858名自1991-93年診斷出第2型糖尿病患者，利用腹部超音波於2001年進行膽結石篩檢，第一階段共有440人(51.3%)完成檢查。第二階段篩檢則於2002進行，扣除63名已知個案，共281人(74.5%)完成第二次檢查。
結果：本研究發現第2型糖尿病患者之膽結石盛行率為14.4%，其中單一結石8.0%、多重結石3.2%、接受過膽囊切除術為3.2%。而邏輯式迴歸分析則發現，膽結石相關因子包括年齡(勝算比=1.06、95%信賴區間=1.02-1.10)及身體質量指數(勝算比=1.11、95%信賴區間=1.01-1.22)。經由一年之追蹤，在281名篩檢族群中發現10例新病例，估計其發生密度為3.56%(年) (95%信賴區間= 1.78% (年)-6.24% (年))。由Cox迴歸模式可知，年齡(相對危險性=1.07、95%信賴區間=1.00-1.14)、腰圍(相對危險性=1.12、95%信賴區間=1.01-1.29)、及ALT(相對危險性=1.13、95%信賴區間=1.01-1.26)為影響膽結石發生的危險因子。至於血清胰島素、胰島素抗性、及�珩茩M功能對女性的影響大於男性。
結論：除了估計盛行率及發生率之外，本研究證明了膽結石的相關危險因子，包括年齡、肥胖、及肝功能指數等。並同時發現血清胰島素、胰島素抗性、及(細胞功能對膽結石的影響有性別上的差異。在日後進一步探討致病機轉時有必要考慮性別的因素。

Background. There are few well-organized community-based screening programs for gallstone disease among type 2 diabetics in Taiwan. This population-based follow-up study is conducted to assess the prevalence and associated risk factors, and the incidence and predictors of gallstone disease (GSD) among type 2 diabetics in Kinmen, Taiwan.
Purposes. The purposes of this community-based study include three parts:
1. To estimate the prevalence of GSD and associated factors related to GSD
among type 2 diabetics.
2. To estimate the incidence and risk factors of GSD among type 2 diabetics
based on the 1-year follow-up period.
3. To explore the relationship between serum insulin, insulin resistance, ��-cell dysfunction and GSD among type 2 diabetics.
Methods. Based on a total of 858 type 2 diabetics ascertained in 1991-93, an ultrasound sonography screening was performed by a panel of specialists in 2001. A total of 440 (51.3%) subjects were examined. In addition, after excluding 63 subjects with GSD, 377 participants without GSD were invited in 2002 for a second round of screening. A total of 281 (74.5%) subjects were re-examined.
Results. Sixty-three out of 440 type 2 diabetics were diagnosed with GSD. The overall prevalence of GSD was 14.4%, including single stone 8.0% (n=35), multiple stones 3.2% (n=14), and cholecystectomy 3.2% (n=14). The significant risk factors of GSD based on multiple logistic regression analysis were age (OR=1.06, 95%CI: 1.02-1.10) and BMI (OR=1.11, 95%CI: 1.01-1.22). Among the 281 type 2 diabetics who had no GSD at the first screening, 10 subjects had developed GSD by 2002. The incidence was 3.56% per year (95%CI: 1.78% per year-6.24% per year). Using a Cox regression model, age (RR=1.07, 95%CI: 1.00-1.14), waist circumference (RR=1.12, 95%CI: 1.01-1.29), and ALT (RR=1.13, 95%CI: 1.01-1.26) appeared to be significantly related to development of GSD. Serum insulin, insulin resistance, and β-cell dysfunction are risk factors for GSD in female but not male type 2 diabetics. Conclusions. In conclusion, in addition to prevalence and incidence density are estimated based on the community-based study, there are several other findings shown in the present study. Firstly, the older age and higher BMI are associated with the risk of prevalent GSD in type 2 diabetics. Secondly, significant risk factors for the development of GSD include not only older age, but also, higher waist circumference and elevated ALT levels. These results suggested that factors related to type 2 diabetes may be important in the pathogenesis mechanism of the increase risk of GSD among type 2 diabetics. Thirdly, there are gender differences with regard to the relationships between serum insulin, insulin resistance, β-cell dysfunction, and GSD (after adjustment for confounding factors). These observations suggest that factors related to type 2 diabetes might need to be considered separately in male and female diabetic patients in the pathogenic mechanism of increased risk of GSD.

Abstract ………………………………………………………………………... 4
中文摘要……………………………………………………………...…………. 7
Introduction ……………………………………………..…………………... 9
Objectives………………………………………….……….……… 12
Literatures Review…………………….………………..…………………. 13
The Clinical Diagnosis of Gallstone Disease..……………………... 13
The Morbidity of Gallstone Disease ……..…………………………… 14
The Natural History of Gallstone Disease…………………………... 17
The Management of Gallstone Disease……………………………… 18
Materials and Methods…………………….…………………………….. 21
Organization of Gallstone Disease Screening for Type 2 Diabetics in Kinmen…………………………………………………………………… 21
Data Collection of and Diagnosis of Gallstone Disease…….……. 22
Inter-observer Reliability in Ultrasound Sonography……………….. 23
Assessment of Insulin Resistance and β-cell Dysfunction………. 23
Statistical Analysis……………………………………………………… 24
Results……………………………………………………………… 26
Prevalence and Associated Factors of Gallstone Disease among Type 2 Diabetics in 2001 in Kinmen…..……………………………….. 26
Incidence and Risk Factors of Gallstone Disease among Type 2 Diabetics……………………………………………………………………. 27
Serum Insulin, Insulin Resistance, β-cell Dysfunction, and Gallstone Disease among Type 2 Diabetics……….…………………. 29
Discussion…………………………………………………………. 32
The Implications of Prevalence and Associated Factors for Gallstone Disease………………………………………………………….
32
Incidence and Risk Factors for the Development of Gallstone Disease……………………………………………………………………… 34
Implications of Insulin Resistance and β-cell Dysfunction for Gallstone Disease………………………………………………………….. 38
Methodological Consideration…………………………………………… 41
Conclusions…………………………………………………………. 43

List of Tables and Figures
Table 1 The response rate of screening for gallstone disease among
type 2 diabetics in Kinmen, 2001………………………………………. 44
Table 2 The prevalence of gallstone disease among type 2 diabetics in Kinmen, 2001…………………………………………………………….. 45
Table 3 Comparison of characteristics between gallstone disease subjects and controls among type 2 diabetics in Kinmen……………………… 46
Table 4 Multiple logistic regression on the risk factors associated with the gallstone disease among type 2 diabetics in Kinmen……………….. 47
Table 5 The response rate of gallstone disease screening among type 2 diabetics in Kinmen……………………………………………………… 48
Table 6 Gender- and age-specific incidence of gallstone disease among
type 2 diabetics in Kinmen……………………………………………. 49
Table 7 Univariate analysis of risk factors for the development of gallstone disease among type 2 diabetics in Kinmen………………………….. 50
Table 8 Cox regression model of risk factors associated with the development of gallstone disease among type 2 diabetics in Kinmen 51
Table 9 Crude and age-adjusted odds ratio of baseline associated factors of gallstone disease among type 2 diabetics in Kinmen……………….. 52
Table 10 Multiple logistic regression of association between baseline serum insulin, insulin resistance, β-cell dysfunction and gallstone disease among type 2 diabetics in Kinmen……………………………………. 53
Figure 1 The procedure of screening for gallstone disease among type 2 diabetics during 2001-2002 in Kinmen……………………………… 54
Figure 2 Gender and age-specific prevalence of gallstone diseases among type 2 diabetics in Kinemn……………………………………………. 55
References…………………………………………………………. 56
Appendix…………………………………………………………….. 64

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