http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/24 2026-03-10T13:40:31Z http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/29119 標題: 鼻咽癌與FAS、FASL、NF-κB 和 TRAF3基因多形性之流行病學研究; Epidemiological Study on Nasopharyngeal Carcinoma and Genetic Polymorphisms of FAS, FASL, NF-κB and TRAF3 作者: Guan-Yuan Liou; 劉冠嫄 摘要: 背景介紹:鼻咽癌 (nasopharyngeal carcinoma, NPC) 是一種在其他族群非常罕見，但卻是中國南方和東南亞常見的癌症。過去文獻指出遺傳因子和環境因子共同在鼻咽癌的發展過程中扮演重要角色，包括Epstein-Barr virus (EBV) 感染、飲食因子例如中國鹹魚、職業上的暴露、家族性聚集傾向，宿主易感受性遺傳因子都被證實和鼻咽癌的危險性有關。EB病毒在體內的持續性感染被視為鼻咽癌致病機轉的重要因素之ㄧ，EB病毒會引起B細胞的不朽化。腫瘤壞死因子受體相關因子3 (tumor necrosis factor receptor-associated factor3, TRAF3) 為細胞內辨識EB病毒進而引起第一型干擾素的重要因子，同時也會和EB病毒轉譯的潛伏膜蛋白1 (latent membrane protein 1, LMP1) 結合而引起B淋巴細胞的轉形。FAS (CD95, APO-1)、FAS配體 (FASL) 和 核因子-κB (nuclear factor-kappa B, NF-κB) 在細胞凋亡的訊息傳遞路徑扮演重要的角色。本研究欲探討細胞凋亡相關基因多形性與鼻咽癌發生的相關性。 研究方法:總共有317名經由組織病理學確認的鼻咽癌病患與268名符合條件的健康對照納入本研究。從台北市兩大醫院中選取確診為鼻咽癌的個案為病例組，依病例的性別、年齡(每五歲一組，在相同年齡組別中)、居住地作1:1個別配對，從戶籍資料系統中選取符合條件的為對照組。訪員對納入收案對象以結構式問卷進行標準化訪視，取得個案的社會人口學及暴露鼻咽癌相關危險因子的資料，抽取個案周邊血，血清進行EB病毒抗體標誌的檢測；白血球的DNA進行細胞凋亡相關基因的單一核苷酸多形性分析。結果以卡方檢定和費雪精確檢定分析病例組與對照組的基本人口學變項、危險因子狀態及基因頻率分布，以適合度檢定對照組的基因頻率是否符合哈溫平衡，利用非條件式羅吉斯迴歸方式評估單一核苷酸多形性(single nucleotide polymorphism, SNP) 標記對鼻咽癌的危險性。所有的危險性估計值都有調整年齡、性別、教育程度和種族。 結果: FAS (-1377)、FAS (-670)、FASL (-844) 和NF-kB(-94)之基因型與鼻咽癌發生的危險性沒有統計顯著相關，FAS (-1377) 和 FAS (-670) 所建構的haplotype和鼻咽癌的發生也沒有統計顯著相關，而在TRAF3基因上，若600的位置為AA或AG基因型有較高的鼻咽癌發生風險(ORadj, 1.85; 95% CI, 1.12-3.04)。將病例組以鼻咽癌家族病史進行分層分析，發現TRAF3基因型和鼻咽癌家族病史沒有統計顯著相關，。在對照組與病例組，EB病毒的抗體陽性狀態與TRAF3基因型也無統計顯著相關。在感染EB病毒之溶解期相關蛋白的抗體標誌陽性狀況下，TRAF3基因型與鼻咽癌發生有統計顯著相關。 結論: TRAF3 (codon 600) 的基因多形性與鼻咽癌的發生有密切相關；而FAS、FASL 和NF-kB的基因多形性，則與鼻咽癌無統計顯著相關。; Background: Epstein-Barr virus (EBV) infection is an important risk factor for nasopharyngeal carcinoma (NPC). EBV causes the immortalization and transformation of infected cells. Tumor necrosis factor receptor-associated factor 3 (TRAF3) is required for EBV recognition and initiation of type I interferon production. It is also required for activation of B lymphocytes by EBV latent membrane protein 1 (LMP1). FAS (CD95, APO-1), FAS ligand (FASL) and nuclear factor-kappa B (NF-κB) also play important roles in the apoptosis. This case-control study aimed to examine the associations between NPC and polymorphisms of these genes. Methods: A total of 317 cases affected with histologically confirmed NPC and 268 healthy community controls matched with cases on gender, age and residence were enrolled. Blood samples were collected for the examination of IgA antibodies against EBV-specific viral capsid antigen (anti-EBV VCA IgA) and Epstein-Barr nuclear antigen 1 (anti-EBNA 1 IgA) and IgG antibodies against DNA binding protein (anti-EBV DBP IgG) and DNase (anti-EBV DNase IgG). The real-time PCR assay was used for genotyping of TRAF3 (codon 600), FAS (-1377 and –670), FASL (-844) and NF-κB (-94). Logistic regression analysis was used to estimate multivariate-adjusted odds ratio (ORadj) with its 95% confidence interval (CI) for each genotype after adjustment for age, gender, educational level, and ethnicity. Results: Genetic polymorphisms of FAS (-1377), FAS (-670), FASL (-844) and NF-kB (-94) were not significantly associated with the risk of NPC. The haplotype of FAS (-1377 and -670) was not significantly associated with NPC risk either. Individuals with the TRAF3 (codon 600) AA or AG genotype had an increased NPC risk compared with GG genotype as the referent group (ORadj, 1.85; 95% CI, 1.12-3.04). In NPC cases, family NPC history was not associated with TRAF3 (codon 600) genotype. The seropositivity of various antibodies against EBV was not significantly associated with TRAF3 (codon 600) genotype in either NPC cases or controls. TRAF3 (codon 600) genotype was associated with an increased risk of NPC in those who were seropositive on anti-EBV VCA IgA, anti-EBV DBP IgG, and anti-EBV DNase IgG. Highest NPC risk was observed for those who were anti-EBV-seropositive with AA/AG genotype of TRAF3 (codon 600). Conclusions: There is a significant association with NPC for TRAF3 genotype, but not for FAS, FASL and NF-κB genotypes. TRAF3 (codon 600) AA/AG genotype was associated with an increased risk of NPC compared with GG genotype, especially in those who were seropositive on antibodies against EBV proteins expressed in lytic infection. 2007-01-01T00:00:00Z http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/99915 標題: 鼻咽癌患者經放射治療後缺血性腦中風的預防與預測; Prevention and Prediction of Ischemic Stroke in post Radiotherapy Nasopharyngeal Carcinoma Patients 作者: 林傳益; Chuan-Yi Lin 摘要: 背景：在台灣，鼻咽癌是第二常見的頭頸癌，佔所有癌症病例的5%以及頭頸癌的50%。放射治療是治療鼻咽癌最有效的方法，然而放射線治療照射部位包含顱底與頸部可能導致頸動脈狹窄，進而增加缺血性中風的風險。在現代，結合強度調控放射治療與全身化學治療，非遠端轉移的末期鼻咽癌患者的預後極佳。隨著長期存活者人數增加，預測與預防晚期放射治療相關併發症的重要性日益提升。 研究目的與方法：第一個研究目標（研究一）是評估在接受標準同步化學放射治療之晚期鼻咽癌患者中，使用他汀類藥物對缺血性中風風險的影響。在研究一中，我們使用了台灣癌症登記資料庫（TCRD）與台灣全民健康保險研究資料庫（NHIRD）連結的全國性資料。我們採用逆機率加權（IPTW）Cox 回歸分析，以探討在同步化學放射治療期間使用他汀類藥物與缺血性中風風險之間的關聯性。第二個研究目標（研究二）是建立一套風險預測模型，以辨識在接受放射治療後可能發展為中度以上內頸動脈狹窄的高風險鼻咽癌患者族群。研究二的資料來源為台大醫院整合醫療資料庫（NTUH-iMD）中的電子病歷資料。我們分析接受放射治療後鼻咽癌患者頸內動脈狹窄的風險因子，並利用逐步變數選擇法建立 Cox 比例風險模型的風險預測模型。此外，我們建立了接收者操作特徵曲線（ROC curve）與布萊爾分數（Brier score)，以評估該風險預測模型的判別能力與整體表現。第三個研究目標（屬於研究二）是釐清接受放射治療後鼻咽癌患者進行頸動脈超音波篩檢的最佳起始時機。為了闡明風險的時間分布，我們應用多變量廣義線性混合模型（Generalized Linear Mixed Model, GLMM），以判定放射治療後與發生中度以上內頸動脈狹窄最密切相關的年度時間點。 結果：在研究一中，相較於未使用他汀類藥物的族群，使用他汀類藥物患者的缺血性中風調整後風險比（aHR）為0.70（95%信賴區間：0.54–0.92；P 值為 0.0107）。累積規定日劑量（cDDD）分析顯示劑量反應關係，在 cDDD 較高的四分位數中觀察到較低的缺血性中風風險。此外，日定義劑量（DDD）大於 1 的患者缺血性中風風險降低，其 aHR 為 0.49（95%CI：0.31–0.63）；而DDD 小於或等於 1 的患者，其 aHR 為 0.59（95% CI：0.40–0.84）。在研究二中，根據我們建立的預測模型，風險分數達 5 分以上的高風險族群，其發生中度或以上內頸動脈狹窄的風險明顯增加，且可能在接受放射治療後的第四年即開始出現。此外，我們發現，相較於整體族群的平均風險，發生中度或以上內頸動脈狹窄的風險大約在放射治療後第七年左右開始顯著且持續上升。 結論：我們的研究一提供了證據，支持在接受標準同步化學放射治療的晚期鼻咽癌患者中，他汀類藥物於治療期間使用，能有效降低放射治療引起的缺血性中風風險。在研究二中，根據我們提出的風險預測模型，我們建議鼻咽癌患者於放射治療後第七年開始進行頸動脈超音波篩檢，而高風險族群患者則應提早開始於放數線治療後第四年即開始篩檢。; Introduction: In Taiwan, nasopharyngeal carcinoma (NPC) is the second most common type of head and neck cancer, accounting for approximately 5% of all cancer cases and representing nearly 50% of all head and neck malignancies. Radiotherapy (RT) serves as the most effective treatment for NPC but can induce carotid stenosis and increase the risk of ischemic stroke. In modern era of intensity modulated radiation therapy (IMRT) and effective systemic chemotherapy, prognosis of patients with localized NPC is excellent. With larger number of long-term survivors, the prediction and prevention of late RT-related complications has become important. Study Aims and Methods: The aim 1 of this doctoral dissertation (study 1) is to evaluate the impact of statin use on ischemic stroke risk in patients with advanced NPC undergoing standard concurrent chemoradiotherapy (CCRT). In the first study, we utilized nationwide data from the Taiwan Cancer Registry Database (TCRD), which was linked to the National Health Insurance Research Database (NHIRD) of Taiwan. In Study 1, We applied an inverse probability of treatment-weighted (IPTW) Cox-proportional hazards regression model to examine the association between statin use during CCRT and the risk of ischemic stroke. The aim 2 of this doctoral dissertation (Study 2) is to develop a risk prediction model to identify high-risk groups of NPC patients who are likely to develop moderate or greater internal carotid artery (ICA) stenosis after receiving RT. In the second study, the data source is from electronic medical record from National Taiwan University Hospital, integrative Medical Database (NTUH-iMD). We investigated the risk factors of ICA stenosis in post-RT NPC patients and developed risk prediction model by using stepwise variable selection in Cox proportional hazard model. The Receiver Operating Characteristic (ROC) curve and integrated Brier score were constructed to assess the discriminatory ability and overall performance of our risk prediction model. The aim 3 of this doctoral dissertation (study 2) is to determine the optimal timing for initiating carotid ultrasound screening in post RT NPC patients. To elucidate the temporal pattern of risk, a multivariable Generalized Linear Mixed Model (GLMM) was applied to determine the post-radiotherapy year most strongly associated with the onset of moderate or greater ICA stenosis. Results: In Study 1, the adjusted hazard ratios (aHR) for ischemic stroke in the statin group compared to the non-statin group was 0.70 (95% CI: 0.54–0.92). Analysis based on cumulative defined daily doses (cDDD) demonstrated a clear dose–response relationship, with a progressively lower risk of stroke observed in higher cDDD quartiles. Furthermore, patients with a daily defined dose (DDD) greater than 1 had a significantly reduced stroke risk (aHR: 0.49; 95% CI: 0.31–0.63), whereas those with a DDD of 1 or less also showed a protective effect (aHR: 0.59; 95% CI: 0.40–0.84). In study 2, according to our predictive model, patients in the high-risk group (risk score≥5) have significantly increased risk of moderate or greater ICA stenosis, which may begin to manifest as early as the fourth year after receiving radiation therapy. Additionally, we found that, compared to the average risk of the entire cohort, the risk of developing moderate-to-severe ICA stenosis began to increase significantly and persistently around the seventh year after radiotherapy. Conclusions: Study 1 provides compelling evidence supporting the beneficial effects of statin use during the CCRT period in reducing the risk of radiation-induced ischemic stroke among patients with advanced NPC undergoing definitive CCRT. In the study 2, according to our proposed risk prediction model, we recommend that carotid ultrasound screening begin in the seventh year following radiation therapy, while high-risk patients should start screening earlier, beginning in the fourth year. 2025-01-01T00:00:00Z http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/29048 標題: 鼻咽癌多重篩檢工具的評估; Evaluation of Multiple Detection Modalities for Nasopharyngeal Carcinoma 作者: Chih-Chieh Tseng; 曾智傑 摘要: 從篩檢實務面來看，利用單一檢測工具篩檢疾病時雖然有方法簡便和價格便宜的優點，但是卻有敏感度和精確度不足的問題。為了增加篩檢敏感度和精確度，我們就需要合併多重檢測工具的方式，然而多重檢測工具之使用在方法學上我們會遇到一些問題，是單一檢測工具無法解決的問題，例如多重檢測工具合併後的敏感度和精確度、檢測工具多早前可以偵測出疾病，以及如何應用多重篩檢工具敏感度及精確度於多重檢測工具的成本效益問題。以鼻咽癌而言，利用單一工具EBV VCA IgA篩檢鼻咽癌時，會有精確度不足及偽陽性太高的問題。為了同時增加篩檢工具的敏感度和精確度，就需要合併多重鼻咽癌的檢測工具。然而合併了多重檢測工具後，篩檢的成本也隨之提高，因此就需要各種篩檢方法經濟效益的分析。本論文主要研究的目的為：(1)利用貝氏固定和隨機模式進行單一檢測工具敏感度和精確度的整合分析模式。(2)多重檢測工具的條件相依模式。(3)利用多階段模式估計多重檢測工具的臨床偵測前期與敏感度之關係。(4)利用(3)的結果進行鼻咽癌的多重檢測工具的成本效益分析。 本研究以發展多重篩檢工具的方法學並將之應用於鼻咽癌早期發現，其架構如下： 1. 以系統性文獻回顧方式，搜尋Medline和PubMed兩大外文資料庫，計收錄關鍵字含screening, Ebstein-barr virus (EBV)和Nasopharyngeal carcinoma文章計36篇，由於各研究間存在著異質性，因此我們分別以貝氏固定效應模式和貝氏隨機效應模式進行整合性分析，得到鼻咽癌篩檢單一工具的敏感度及精確度。 2. 進一步進行同時考慮兩種工具的整合性分析，由於兩種測量工具存在生物相似性，因此我們引入貝氏條件相依模式進行整合性分析。 3. 利用敏感度和臨床偵測前期之間的關係求算利用不同檢測工具進行篩檢時，由該工具最早可偵測時間點到臨床症狀發生之時間間隔。 4. 考慮利用兩種工具進行檢測時，族群內的個體可能存在何種工具較早可偵測到的順序不一致的情況，因此我們發展一混合性多階段疾病自然史模式，利用電腦模擬方式產生虛設世代，並進行參數估計及模式驗證。 5. 利用(4)的結果進行僅用單一工具(EBV VCA IgA或Nasopharyngoscope)及併用兩種工具相較於不篩檢時的經濟評估。 本研究貝氏隨機效應模式整合分析的結果發現敏感度最高的是EBV BamHI-W[中位數為91% (95%CI=67-97%)]，其次為EBV VCA IgA (cross-sectional)、Nasopharyngeal swab、EBV VCA IgA、EBV EA IgA、Nasopharyngoscope及EBV EBNA。精確度最高的是Nasopharyngoscope [中位數為98% (95%CI=66-99%)]，其次為EBV EA IgA、EBV VCA IgA (cross-sectional)、EBV BamHI-W、EBV EBNA、Nasopharyngeal swab及EBV VCA IgA。貝氏固定效應模式亦有相似的發現，但由模式的DIC值顯示大部份隨機模式均較固定模式來的好，除了鼻咽拭子之外。再利用多重檢測工具的敏感度、轉移速率和臨床偵測前期的關連，可得利用EBV BamHI-W檢測的臨床症前期約為2.79年，鼻咽拭子約為2.77年，EBV VCA IgA約為2.68年，EBV EA IgA、EBV EBNA及鼻咽鏡為2.34年，鼻咽細胞學為2.22年，合併鼻咽內視鏡和EBV VCA IgA、合併EBV EA IgA和EBV VCA IgA及合併EBV EBNA和EBV VCA IgA為2.97年。合併EBV BamHI-W和EBV VCA IgA 3.01年。 利用混合性多階段疾病自然史模式所得估計結果接近提供的真值，利用估計值得到僅使用EBV VCA IgA、僅使用鼻咽內視鏡及合併兩種工具的敏感度分別為87.6%, 72.4%及97.4%，與之前整合式分析結果相近。進一步利用以上參數比較未篩檢，利用EBV VCA IgA及鼻咽鏡每一年或每兩年篩檢一次，結果發現和未篩檢比較，每2年EBV VCA IgA篩檢的增加成本效益比例(ICER)是NT365,095、每年EBV VCA IgA篩檢的增加成本效益比例(ICER)是NT442,145，而每年合併EBV VCA IgA和鼻咽鏡篩檢的增加成本效益比例(ICER)是NT1,091,533。和未篩檢比較，每2年EBV VCA IgA篩檢17,857人可以減少一個鼻咽癌死亡。每年EBV VCA IgA篩檢23,622人可以減少一個鼻咽癌死亡。每年合併EBV VCA IgA和鼻咽鏡篩檢21,739人可以減少一個鼻咽癌死亡。 本研究最大新穎想法是將多階段模式疾病隨時間進展之概念與篩檢敏感度之相關進行聯結及互轉，此方法若應用於篩檢實務，將可提供做篩檢政策之參考，如篩檢間隔的決定及成本效益分析。; Disease screening with single detection modality is convenient and cheap, but it may be less effectiveness in terms of sensitivity and specificity. In order to solve this problem, multiple detection modalities may be needed. However, the methodology of combining multiple detection modalities is difficult, such as the combined sensitivity and specificity, detection ability, and cost-effectiveness analysis. Take screening of nasopharyngeal carcinoma (NPC) with EBV VCA IgA for example. The specificity of EBV VCA IgA is not good enough that the false positive rate is too high. Although multiple detection modalities can raise sensitivity and specificity at the same time, it will also increase the cost of screening. Therefore, the cost-effectiveness analysis of multiple detection modalities ensures. The purpose of this study is to complete (1) the meta-analysis of sensitivity and specificity of each detection modality using Bayesian fixed-effect and random-effect model, (2) conditional dependency model of multiple detection modalities, (3) the relation between sensitivity and sojourn time using multi-state model, (4) the cost-effectiveness of multiple detection modalities for NPC. The methodology part of multiple detection modalities is described as following: (1) We systemically searched Medline and PubMed with the key words of screening, Ebstein-barr virus(EBV) and nasopharyngeal carcinoma. The meta-analysis of the included 36 literature was performed with Bayesian fixed-effect and random-effect model to deal with the heterogeneity between each study. The results of sensitivity and specificity of each detection modality were obtained. (2) We used Bayesian conditional dependency model to estimate the combined sensitivity and specificity of detection modalities. This model adjusted with the biological correlation between combined detection modalities. (3)With the relation of sensitivity and pre-clinical detectable phase (PCPD, sojourn time), we estimated the earliness of detectable phase of each modalities. (4)We proposed a multi-state model for a mixture type of tumor progression. We also simulated the parameters for the mixture type model with the method of Monte Carlo simulation. Validation of the parameters was also performed. (5) We completed the cost-effectiveness analysis of NPC screening with different screening strategies using the parameters we generated in (4). The results of meta-analysis of the sensitivity for different detection modalities for nasopharyngeal carcinoma with Bayesian random-effect model are described as following. Serology of EBV BamHI-W region gene is the most sensitive detection modality (median value of 91%), followed by nasopharyngeal swab , EBV VCA IgA , EBV EA IgA , EBV EBNA, and nasopharyngoscope. In the same way, the most specific detection modality is nasopharyngoscope (median value of 98%), followed by EBV EA IgA, nasopharyngeal swab, EBV BamHI-W, EBV VCA IgA and EBV EBNA. The results of Bayesian fixed-effect model were similar to that of random-effect model. Using DIC (Deviation information criteria) to compare the two models, we found the random-effect model is better than fixed-effect model. The results of PCDP of each detection modalities were obtained with the relation between sensitivities, transitional rates, and PCDP. The PCDP of EBV BamHI-W is 2.79 year, nasopharyngeal swab is 2.77 year, EBV VCA IgA is 2.68 year, EBV EA IgA, EBV EBNA and nasopharyngoscope are 2.34 year, and nasopharyngeal cytology is 2.22 year. The PCDP of combining nasopharyngoscope and EBV VCA IgA, EBV EA IgA and EBV VCA IgA, and EBV EBNA and EBV VCA IgA is the same, 2.97 year. The PCDP of combining EBV BamHI-W and EBV VCA IgA is longest, 3.01 year. The estimated value is close to the true value in the model of mixture type tumor by simulation method. The sensitivity of simulation model is also close to that of meta-analysis. In cost-effectiveness analysis, the ICER (incremental cost-effectiveness ratio) is 365,095 when the strategy of no screening and 2-year screening with EBV VCA IgA is compared. The ICER is 442,145 with no screening and annually screening with EBV VCA IgA. The ICER is 1,091,533 with no screening and annually screening with combining EBV VCA IgA and nasopharyngoscope. Compared with no screening, 2-year screening with EBV VCA IgA can reduce one NPC death per 17,857 screening, annual screening with EBV VCA IgA can reduce one NPC death per 23,622 screening, and annual screening with combining EBV VCA IgA and nasopharyngoscope can reduce one NPC death per 21,739. The novelty of this study is combining the idea of sensitivity and multi-state model. In this way, the sensitivity of detection modalities has taken the influence of time progression into account. This method can be applied in disease screening in terms of screening interval determination and cost-effectiveness analysis. 2007-01-01T00:00:00Z http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/9424 標題: 麻醉學專科筆試項目能鑑度反應分析; Item Response Analysis for Data on Written Examinations in Anesthesiology 作者: Kuang-Yi Chang; 張光宜 摘要: 專科醫師測驗的目的在於評估考生是否足以勝任執業的最低要求。雖然專科醫師測驗對醫療照護品質而言相當重要，但是目前仍缺乏相關研究對專科醫師測驗結果進行詳盡的試題分析。事實上測驗中的項目反應隱含豐富且有價值的測驗訊息值得進行更多的相關研究。有鑑於此，本研究的主要目的為利用項目反應模式針對2007至2010年的台灣麻醉專科醫師筆試測驗進行廣泛的項目反應分析。 這四個年度的麻醉專科醫師筆試測驗均為100道單選題，應考人數介於34至37人之間。本研究採用兩種不同分析策略進行項目反應分析，先利用最大概似估計法估計模式參數與測驗信度，再將貝氏項目反應分析應用在更複雜模式的參數估計、不同模式的模式比較、評估共變數對考生能力的影響與多階層項目反應分析。 研究結果顯示這四個年度台灣麻醉專科醫師筆試測驗的信度介於0.71至0.75之間。兩種估計方式都可以得到單參數項目反應模式的考生能力與試題難度參數。但是在估計更複雜的雙參數與三參數模式時，最大概似估計法會遭遇無法收斂的問題。而貝氏法所得到的三參數模式估計結果顯示有過度參數化的疑慮，因此將所有猜題參數設為相等重新進行分析後發現這個共同參數的值接近於0。模式比較結果有利於採用單參數項目反應模式。而所收集到諸如考生年齡、性別與其訓練中心地理位置等變項對考生能力皆無顯著影響，階層項目反應分析結果顯示來自於同一中心考生彼此間的能力有相關性存在。 本研究證實了針對台灣麻醉專科醫師筆試測驗所進行的項目反應分析可以為將來的命題提供有用的資訊，而貝氏項目反應分析的彈性與多功能性對台灣麻醉專科醫師測驗的試題分析具有重大價值。; Board certification examinations for medical specialists aim to evaluate whether an examinee is competent to exceed minimum requirement for clinical practice. Although board certification examinations are of paramount importance to the quality of medical care, there is still lack of thorough investigations which focused on item response analyses of board certification examinations in a medical specialty. Item responses in a test are influenced by the examinee ability and item difficulty which require an in-depth statistical analysis. Therefore, the major goal of this thesis was to conduct comprehensive item response analyses on written tests of the Taiwanese board certification examinations in anesthesiology from 2007 to 2010 using a series of item response theory models. Data were derived from one hundred multiple choice items with single best answer included in each certification examination. The number of examinees ranged from 34 to 37 in each year for these four years. Two analytical strategies were applied to the item response analyses on the written tests of the Taiwanese board certification examinations in anesthesiology. The maximum likelihood estimation (MLE) method was used at first to estimate the parameters of the examinee ability and item difficulty and evaluate test reliability based on the one-parameter logistic (1-PL) model, so-called the Rasch model. Bayesian item response analyses were applied to dealing with more complicated item response models, including the two-parameter logistic (2-PL, considering item discrimination) and three-parameter logistic models (3-PL, considering guessing parameter). Bayesian approach was also used to assess the effects of covariate such as age gender, and geographic area on examinee ability. Bayesian multi-level model was also adopted to consider hierarchical data resulting from the correlation of item response within the same training center. The test reliability of written tests of board certification examination in Taiwan ranged between 0.71 and 0.75 in these four years. Both analytical approaches could estimate parameters of examinee ability and item difficulty in the one-parameter logistic item response model but the MLE methods encountered convergence problems during parameter estimation of the 2-PL and 3-PL item response models. The 3-PL model without restriction on guessing parameters based on Bayesian methods may lead to overparameterization. The common guessing parameters in the restricted 3-PL models with Bayesian approach were close to 0 in all the certification examination in anesthesiology held during the four-year study period. Model comparisons based on deviance information criteria provided evidence in favor of the 1-PL model. The effects of examinee characteristics such as gender, age and location of training centers on ability levels of examinees were not statistically significant. The application of multi-level Bayesian model to hierarchical data revealed correlation between ability levels of examinees from the same training centers. The effect of training center on examinee ability was not salient. This thesis demonstrates that item response analyses on written tests of the Taiwanese board certification examinations can provide useful information on test development in the future. The flexibility and versatility of Bayesian item response analyses were of great value for test analysis on written tests of the Taiwanese board certification examinations in anesthesiology. 2011-01-01T00:00:00Z