臺灣博碩士論文加值系統

第一篇論文:
本研究的目的是瞭解煉油廠員工其慢性肝炎病毒感染的情形、主要慢性肝病的種類及其盛行情況，並探究其主要危險因子。並嘗試探討石油溶劑暴露對該廠員工的影響。研究對象是臺灣南部某石化公司嘉義廠區的員工，選取方式採自願參加。健康資料之蒐集包括問卷填寫、最近四年勞工健康檢查資料及腹部超音波檢查。有345人完成問卷調查，其中326人接受腹部超音波檢查。工作暴露分類是依據研究者進行各部門之實地訪視，另外再參照問卷調查判斷。本廠之原料及產品均是脂肪烴和芳香烴等石油溶劑，但不含苯、甲苯或二甲苯。其製程是以蒸餾、精餾、摻配、加氫為主，並不包括脫硫。危險因子的分析方面，以ALT持續異常、脂肪肝、肝實質病變為依變項，自變項則包括性別、年齡、受雇期間、肝炎病毒標記、飲酒、服藥、身體質量指數、糖尿病病史、膽固醇、三酸甘油脂、工作暴露情況。結果發現，脂肪肝是本廠區最盛行之肝病，盛行率約28%；肝炎病毒感染次之，其中HBsAg陽性率16.5%、antiHCV陽性率3.6%。脂肪肝最重要的因素是肥胖，肝實質病變最主要危險因子是肝炎病毒感染。ALT持續異常的最重要危險因子也是肥胖，其次是肝炎病毒感染。肥胖和肝炎病毒感染是本廠區員工慢性肝病的最主要危險因子。在職場進行肝病管理時，可從這兩個主要危險因子著手，可能對員工的助益最大。本廠員工是屬於長期低劑量的暴露型態，石油溶劑的暴露並非脂肪肝或ALT持續異常的危險因子。工作中使用肝毒性物質的實驗人員，其工作暴露與慢性肝病亦無明顯關係。
第二篇論文:
由於臺灣有特殊的肝病盛行狀況，為了瞭解ALT對於國內勞工慢性肝病的篩檢價值而進行本研究。此外，並針對目前職業衛生管理上的需要，提出建議，以發揮勞工健康檢查的目標。研究對象是臺灣南部某石化公司嘉義廠區的員工，有345人自願參加提供本年勞工健康檢查資料，其中326人接受腹部超音波檢查。本研究所分析之慢性肝病包括脂肪肝、肝炎病毒感染(包括HBsAg陽性、anti-HCV陽性)、肝實質病變等。將ALT每10 U/L做一個分界點，以2 x 2表格算出以每個分界點為篩檢標準之敏感度、特定度、準確度。另外，並以ROC曲線圖的區域下面積(area under curve,AUC)做為整體檢查價值的摘要測量(summary measure)。結果發現，若以參考值上限48 U/L為分界點，則ALT篩檢脂肪肝的敏感度只有約31%，但特定度約95%，因此，以ALT篩檢脂肪肝雖有其效果，但可能會漏掉許多人。以ROC分析ALT篩檢肝實質病變的整體能力顯示並無效果。若是以ALT值做為是否對個人進行肝炎病毒感染篩檢的依據，則其效果亦令人失望，因為分界點放在48 U/L時，有79%的肝炎病毒感染者會被漏掉，但是ALT對於肝炎病毒感染的特定度還不錯，可達88%。因為ALT對脂肪肝、肝實質病變、肝炎病毒感染的敏感度偏低，所以需注意ALT在參考值範圍內，並不表示肝臟一定是健康的，以免錯失了預防疾病的機會。ALT對慢性肝病具有相當高的特定度，所以在慢性肝病盛行率高的臺灣，只要ALT升高，都值得做進一步的檢查以瞭解其原因，進行適當的處置。由於ALT的篩檢價值能力並不理想，因此需要正確地解讀其訊息並輔以及其他檢查工具(如HBsAg)與健康管理，較能發揮其篩檢價值，達到勞工健康檢查的目標。

Part I:
The objective of this study was to determine the prevalence rate and risk factors of chronic liver diseases in an oil refining and research factory. Regular health screening data in recent four years were collected and all 700 workers were asked to fill a questionnaire about their life style. 345 voluntarily participated in the study, and 326 of them were performed abdominal ultrasonography. After conducting a walk-through in the factory identifying all the potential hazard, workers were classified into four exposure zones: administration, utility, manufacture, laboratory. Fatty liver disease (FLD) was found to be the most common problem(28%) , hepatitis virus infection followed by (HBsAg positive rate: 16.5%, anti-HCV positive rate 3.6%). Obesity was the most important risk factor of FLD and hepatitis virus infection was that of parenchymal liver disease (PLD). The major causes of persistent ALT elevation were obesity and hepatitis virus infection. Modeling by multiple logistic regression model demonstrated that exposure to petroleum distillates in this factory was not associated with FLD, PLD and persistent ALT elevation even in workers employed for more than twenty years. However, since this study was a cross sectional one, the possibility of health selection of workers can not be ruled out. Since obesity and virus infection were the two major determinants of chronic liver diseases in the population, it was recommended that controlling these factors may be beneficial to the prevention of related diseases.
Part II:
The high prevalence of hepatitis B virus (HBV) infection in Taiwan was unique in the world. To assess the utility of ALT (alanine aminotransferase ) as the annual screening tool for chronic liver disease in the population , we recruited 345 asymptomatic employees of an oil-refining factory located in for a complete physical examination including abdominal ultrasonography. 326 of them were successfully performed. When the cutoff value of ALT was set at 48 U/L, the sensitivity and specificity were 31%, 95% respectively for the screening for fatty liver disease (FLD). The ROC (relative operating characteristic) analysis indicated low effectiveness for the screening for parenchymal liver disease (PLD) by ALT. Using ALT≧48 U/L as indicator of hepatitis virus infection , 79% employees would be missed. Because of the low sensitivity of abnormal ALT , we recommended that ALT within reference range could not guarantee as completely healthy. However , the high specificity of ALT suggested that workers with elevated ALT should be more carefully studied and managed in Taiwan. To early detect chronic liver diseases, we recommend every worker be screened for hepatitis viral markers during pre-placement examination.

目 次
第一篇 煉油廠員工之慢性肝病盛行率及其危險因子
中文摘要 1
英文摘要 2
前言 3
材料與方法 5
研究對象
工作暴露分類
健康資料蒐集
統計方法
結果 10
研究對象
主要的慢性肝病及其盛行率
主要肝病的危險因子之探討
工作暴露分類和主要肝病的關係
討論 13
研究對象的代表性及族群特徵
超音波診斷的準確性
慢性肝病及肝炎病毒帶原之盛行狀況
ALT持續異常
脂肪肝
肝實質病變
肝腫瘤
主要危險因子的健康管理策略
結論 20
參考資料 21
表目錄 24
表1 研究族群各種健康特性之基本資料, 以及與其他未納入研究的員 工之比較
表2 研究對象各種肝病的盛行狀況
表3 ALT持續異常的變因分析結果:粗勝算比,以及多變項羅吉斯迴歸分析之調整後勝算比
表4 脂肪肝的變因分析結果
表5 肝實質病變的變因分析結果
表6 ALT持續異常與工作暴露類別之分析:公用人員vs行政人員
表7 ALT持續異常與工作暴露類別之分析:生產人員vs行政人員
表8 ALT持續異常與工作暴露類別之分析:實驗人員vs行政人員
表9 脂肪肝與工作暴露類別之分析:公用人員vs行政人員
表10 脂肪肝與工作暴露類別之分析:生產人員vs行政人員
表11 脂肪肝與工作暴露類別之分析:實驗人員vs行政人員
表12 肝實質病變與工作暴露類別之分析:公用人員vs行政人員
表13 肝實質病變與工作暴露類別之分析:生產人員vs行政人員
表14 肝實質病變與工作暴露類別之分析:實驗人員vs行政人員
第二篇 單次ALT檢查對無症狀慢性肝病工人的篩檢價價
中文摘要 35
英文摘要 36
前言 37
材料與方法 39
結果 41
討論 43
結論 46
參考資料 47
表目錄 49
表1 191位健康員工之ALT值的平均值、中位數、眾數、及第95分位數
表2 ALT對脂肪肝、病毒肝炎感染 (包括HBsAg陽性anti-HCV陽性)、肝實質病變之整體篩檢能力，以ROC曲線下面積(AUC)來表示
表3 ALT對脂肪肝之篩檢能力：以敏感度、特定度、準確度來表示
表4 ALT對肝實質病變之篩檢能力：以敏感度、特定度、準確度來表示
表5 ALT對病毒肝炎感染(包括HBsAg陽性anti-HCV陽性) 之篩檢能力：以敏感度、特定度、準確度來表示
表6 ALT對B型肝炎病毒感染(HBsAg陽性)之篩檢能力：以敏感度、特定度、準確度來表示
表7 ALT對C型肝炎病毒感染(anti-HCV陽性)之篩檢能力，以敏感度、特定度、準確度來表示
附錄
附錄一 原料油品 53
附錄二 產品 54
附錄三 石油溶劑煉製流程簡圖 55
附錄四 現場廠訪記錄 57
附錄五 問卷 77
附錄六 臺灣常見各種酒類之酒精濃度及單位體積 79
附錄七 腹部超音波檢查記錄單 80
附錄八 與肝毒性有關之常見藥物表 81
附錄九 ALT對慢性肝病之篩檢能力，以ROC曲線圖來表示 82
附錄十 肝病管理的建議及肝功能異常的處理流程 85

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