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慢性血栓栓塞性肺高壓是一種罕見、嚴重且持續惡化的肺部血管性疾病，隨病程進展，致死率極高，儘早鑑別診斷，方能提供準確治療計劃。本文是一位67歲女性案例，因活動呼吸喘就醫， 初步臆斷為心臟衰竭合併急性惡化，入院後藉由病史詢問、檢驗及理學檢查結果顯示BNP持續上升且心電圖呈現S1Q3T3，初步懷疑可能有肺栓塞併心衰竭，故安排心臟超音波檢查，結果發現有肺動脈高壓（肺動脈壓：62.3 mmHg）與右心衰竭，安排胸部電腦斷層攝影，顯示肺動脈栓塞，隨即召開家庭會議解釋病情後，接受右心導管合併肺動脈血管攝影檢查，最終確診為遠端型慢性血栓栓塞性肺高壓併右心衰竭。經由醫療團隊評估後，治療計劃即以藥物為主，故協助申請標靶藥物Riociguat。針對此類病人，即便臨床表徵不具特異性，仍可依病史詢問、檢驗及理學檢查預測肺栓塞的可能性，之後進入影像學鑑別診斷。換言之，雖然慢性血栓栓塞性肺高壓有其高致命的危險性，倘若能及早做出診斷與治療，便能降低死亡風險。 Chronic thromboembolic pulmonary hypertension is a rare, severe and continuous deterioration of pulmonary vascular disease which has high mortality rate along with disease progression. Earlier di­agnosis could contribute to a more accurate treatment plan. A case of 67-year-old female was admitted to hospital because of exertional dyspnea. She was initially suffering from heart failure with acute deterioration. After admission, the results of medical history inquiry, laboratory data and physical ex­amination revealed that BNP level kept raising and the electrocardiogram showed S1Q3T3, which pul­monary embolism with heart failure was suspected. Therefore, echocardiography revealed pulmonary hypertension (pulmonary artery pressure: 62.3 mmHg) and right heart failure. Pulmonary embolism was noticed on chest computed tomography. Soon after the family meeting of medical condition dis­cussion, the patient received right heart catheterization combined with pulmonary artery angiography, and the final diagnosed is distal chronic thromboembolic pulmonary hypertension with right heart failure. After medical team’s assessment, the treatment plan was based on armaceutical control. Thus, the target therapy of Riociguat was performed. For such type of patients, even with non-specific symptoms, the possibility of pulmonary embolism can still be predicted based on medical history, lab­oratory data, physical examination, and the imaging differential diagnosis. If diagnosis and treatment can be conducted as early as possible, the high mortality rate of chronic hromboembolic pulmonary hypertension can be reduced. &nbsp

高關懷學生有較高的學業適應問題，容易促發偏差行為甚至中輟。為了瞭解他們的學習困境，本研究從 第三空間理論探究他們自學校學習的認同特徵及形成，同時檢視不利於他們學習的學校制度特徵。研究 對象為十位有偏差行為的高關懷學生，選自北部一所升學型國中的三個多元班。研究方法採個別深度訪 談及非參與觀察法。訪談對象為學生、三位多元班主責教師與輔導組長。觀察的三個班別為農耕班、熱 舞班及導航班。以詮釋現象學取向進行資料分析。研究結果發現，他們的認同特徵是不讀書。認同形成 肇因於不懂所學，他們學習壓力相當大，混和許多負向情緒，於是成為課堂局外人，展現課堂偏差、翹 課甚至中輟。他們因應學習壓力的方式，混和逃避、放棄、抗拒、自然反應與偏差行為，不僅無助於改 善困境，反而在學校制度課程屬性、統一規範的課程進度、大班教學與考試範圍下，形成棄學的迴圈。 在課堂規範下，他們受管教而破壞師生關係，連帶討厭課堂。即使師生關係佳，仍不等於支持學習。也 因放棄學習而缺乏支持學習的同儕。當他們從學習轉向玩樂，提高回歸學習的難度，若交往涉及幫派的 同儕，不僅偏差行為加劇，更可能回頭抗拒家庭的管教。 At-risk students have more problems of learning in schools that might lead to delinquent behaviors and drop-out. It is important to find out their difficulties in learning in schools and let at-risk students receive suitable schooling. The research purposes are to investigate the identity and their formation based on the third space theory. This approach could reflect the school systems which would obstruct learning of at-risk students from their coping attitudes. Ten at-risk students who had delinquent behaviors were chosen from three Multiple Classes in a junior high school in Taipei. The school has better high school entrance performance. Multiple Classes teaching various activities but academy are designed for delinquent students who are not able to stay in regular classroom to learn. Classes include gardening, dance and navigation related activites. Research methods are individual in-depth interview and non-participatory observation. Interviewees were students, one teacher from each of the three Multiple Classes and Section Chief of Counseling in school. Observation was conducted in each of three Multiple Classes using video recording and field diary. Data were analyzed by hermeneutic phenomenology approach. Interviews with student were the primary data, and interviews with teachers and class observation served as triangulation. After all cases were analyzed individually, cross cases analysis followed. The results find the identity of at-risk students is to quit learning, and four students identified themselves as to playaround. Regarding identity formation, they bear huge pressure from learning with lots of negative emotions which results from not understanding what they are taught. These emotions led to their delinquency behaviors and marginalization in class, cut classes or even flunk out. Avoiding, giving up, resisting and spontaneous reaction were used by these students to cope with pressure in school. These attitudes relating to misbehaviors can not relieve their difficulties, but form a feedback loop that impeded student learning in the school systems. These school systems are academic curriculum, one-size-fits-all curriculum schedule and tests, and whole class instruction. The loop keeps them from learning, getting harder to follow up classes and even staying away from schools. Class delinquency of students often led to disciplinary actions which worsened teacher-student relationship and their attitude toward the teachers’ classes. Even the relationship is fair, it does not mean to support their learning. Additionally, at-risk students lack of classmates to support their learning after quit learning because common activities of classmates are about learning. If they escape from learning to play around, they spend more time on play and created a vicious circle of low school. Their parents are commonly unfamiliar with their friends frequently hanging on. If they have friends to do with gangsters, they would act more delinquent behaviors and even rebel against their family rules. The contributions of this research are in two perspectives. From research approach perspective, this research adopts third space theory to explore at-risk students learning problems in school. It not only reveals huge pressure experiences by at-risk students in learning but also the school systems that are disadvantageous to their learning. The at-risk student is the title labelled from the authority of school system taking them as different. From practical perspective, the results depict extremely embarrassed situations of at-risk students in learning. Education policy makers and school administrators should adjust the systems to be more flexible and fit better students’ learning conditions. Teachers and consultants should be more sensitive to identifying their explicit delinquent behaviors and interpret such behaviors not as violating rules intentionally but as a warning of their learning difficulties and assist them to overcome. &nbsp

bBackground:/bComplex posttraumatic stress disorder (CPTSD) has recently been added to the ICD-11 diagnostic system for classification of diseases. The new disorder adds three symptom clusters to posttraumatic stress disorder (PTSD) related to disturbances in self-organization (affect dysregulation, negative self-concept, and disturbances in relationships). Little is known whether recommended evidence-based treatments for PTSD in youth are helpful for youth with CPTSD.bObjectives:/bThis study examined whether Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is useful in reducing PTSD and CPTSD in traumatized youth.bMethods:/bYouth (in/i = 73, 89.0% girls,iM/iage = 15.4 SD = 1.8) referred to one of 23 Norwegian child and adolescent mental health clinics that fulfilled the criteria for PTSD or CPTSD according to ICD-11 and received TF-CBT were included in the study. Assessments were conducted pre-treatment, and every fifth session. Linear mixed effects models were run to investigate whether youth with CPTSD and PTSD responded differently to TF-CBT.bResults:/bAmong the 73 youth, 61.6% (in/i = 45) fulfilled criteria for CPTSD and 38.4% (in/i = 28) fulfilled criteria for PTSD. There were no differences in sex, age, birth country, trauma type, number of trauma types or treatment length across groups. Youth with CPTSD had a steeper decline in PTSD and CPTSD compared to youth with PTSD. The groups reported similar levels of PTSD and CPTSD post-treatment. The percentage of youth who dropped out of treatment was not different across groups. Further, the groups did not differ significantly in number of received treatment sessions.bConclusions:/bThis is the first study to examine whether TF-CBT is helpful for youth who have CPTSD using a validated instrument for measuring CPTSD. The results suggest that TF-CBT may be useful for treating CPTSD in youth. These are promising findings that should be replicated in studies with larger sample sizes.bAntecedentes:/bEl trastorno de estrés postraumático complejo (TEPT-C) ha sido agregado recientemente al sistema de diagnóstico para la clasificación de enfermedades CIE-11. El nuevo trastorno agrega tres grupos de síntomas al trastorno de estrés postraumático (TEPT), relacionados con alteraciones en la autoorganización (desregulación afectiva, autoconcepto negativo y alteraciones en las relaciones). Poco se sabe acerca de si los tratamientos basados en evidencia recomendados para el TEPT en jóvenes son útiles para los jóvenes con TEPT-C.bObjetivos:/bEste estudio examinó si la Terapia Cognitiva Conductual Centrada en el Trauma (TF-CBT en sus siglas en inglés) es útil para reducir el TEPT y el TEPT-C en jóvenes traumatizados.bMétodo:/bSe incluyó en el estudio a jóvenes derivados a una de las 23 clínicas noruegas de salud mental para niños y adolescentes, que cumplían con los criterios para TEPT o TEPT-C según el CIE-11 y recibieron TF-CBT (in/i= 73, 89% niñas,iM/isubedad/sub= 15,4,iDE/i= 1,8). Se realizaron evaluaciones antes del tratamiento y cada cinco sesiones. Se ejecutaron modelos de efectos mixtos lineales para investigar si los jóvenes con TEPT-C y TEPT respondían de manera diferente a la TF-CBT.bResultados:/bEntre los 73 jóvenes, el 61,6% (in/i= 45) cumplió con los criterios de TEPT-C y el 38,4% (in/i= 28) cumplió con los criterios de TEPT. No hubo diferencias en sexo, edad, país de nacimiento, tipo de trauma, número de tipos de trauma o duración del tratamiento entre los grupos. Los jóvenes con TEPT-C tuvieron una disminución más pronunciada en TEPT y TEPT-C en comparación con los jóvenes con TEPT. Los grupos reportaron niveles similares de TEPT y TEPT-C después del tratamiento. El porcentaje de jóvenes que abandonaron el tratamiento no difirió entre los grupos. Además, los grupos no difirieron significativamente en el número de sesiones de tratamiento recibidas.bConclusiones:/bÉste es el primer estudio que examina si la TF-CBT es útil para los jóvenes que tienen TEPT-C mediante un instrumento validado para medir el TEPT. Los resultados sugieren que la TF-CBT puede ser útil para tratar el TEPT-C en jóvenes. Estos son hallazgos prometedores que deberían replicarse en estudios con tamaños muestrales más grandes.b背景：/b复杂性创伤后应激障碍 (CPTSD) 最近已被添加到用于疾病分类的 ICD-11 诊断系统中。这种新疾病在创伤后应激障碍 (PTSD)中增加了三个自我组织障碍相关的症状簇（情感失调、消极自我概念和人际关系障碍）。对于青少年 PTSD 的推荐循证治疗对于患有 CPTSD 的青少年是否有帮助尚不清楚。b目的：/b本研究考查了聚焦创伤的认知行为疗法 (TF-CBT) 是否有助于减少受创伤青少年的 PTSD 和 CPTSD。b方法：/b研究纳入了被转诊至 23 家挪威儿童和青少年心理健康诊所之一的符合 ICD-11 PTSD 或 CPTSD 标准并接受了 TF-CBT的青少年（in/i= 73，89.0 % 女孩，平均年龄 = 15.4，标准差 = 1.8）。评估在治疗前进行，每五个疗程进行一次。采用线性混合效应模型以考查患有 CPTSD 和 PTSD 的青少年对 TF-CBT 的反应是否不同。b结果：/b在 73 名青少年中，61.6%（in/i= 45）符合 CPTSD 标准，38.4%（in/i= 28）符合 PTSD 标准。性别、年龄、出生国家、创伤类型、创伤类型数量或治疗时间方面没有组间差异。与患有 PTSD 的青少年相比，患有 CPTSD 的青少年的 PTSD 和 CPTSD 下降幅度更大。这些组别报告了治疗后相似水平的 PTSD 和 CPTSD。退出治疗青少年的百分比无组间差异。此外，各组在接受治疗的次数上没有显著差异。b结论：/b这是第一项使用经过验证的 CPTSD 测量工具考查 TF-CBT 对于患有 CPTSD 的青少年是否有帮助的研究。结果表明，TF-CBT 可能对治疗青少年 CPTSD 有用。这些有希望的发现应该在更大样本量的研究中重复。.

The rapid digital transformation (DX) that airlines experienced during the past decade has been proven to be the driving force of significant benefits for the airlines when it comes to cost reduction, branding and revenue opportunities when passengers purchase tickets and ancillaries directly from their websites. This paper aims to contribute empirically to the theoretical approaches of DX and revenue management (RM) with the investigation of the Aegean airlines DX progress, focusing on emerging RM practices and digital distribution channels.,A content analysis of the airlines’ website and social media performance is used to note the current situation combined with previous and upcoming developments. Evaluation of the company’s digitalization progress is approached by using a combination of two selected DX models, the digital transformation maturity (DTM) concept and the technology acceptance model (TAM).,The analysis of qualitative and quantitative secondary data provided by the Aegean airlines indicates that the adoption of a digital evolution marketing plan, enriched with emerging RM practices, is leading to the increase of the bookings coming from the airline’s direct distribution channels (Web & Apps) over those from intermediaries (GDSs). Consequently, Aegean airlines’ DX progress favors cost reduction and revenue increase at the same time.,DX model-based airline steps combined with direct versus indirect ticket purchase pattern compose a tool to evaluate the airline digitalization progress toward revenue integrity and product customization, as the latest trend in customer-centric strategy of businesses and customer relationship management (eCRM).,近十年来的快速数字化改革（DX）证实了航空体验成为航空公司在降低成本、品牌效应、以及收益机会的时候显著受益的驱动因素, 这体现在当乘客通过网站购买飞机票和附加服务的时候。本论文旨在以Aegean航空DX进展为实例, 以事实来验证DX和收益管理（RM）的理论论断, 尤其在新兴RM措施和数字化分销渠道方面。,本论文采用文本分析航空网站和社交媒体表现的方法, 以展示结合过去和未来发展的目前情况分析。本论文通过结合两种DX模型, 数字化改革成熟概念（DTM）以及科技接受模型（TAM）, 对该航空公司的数字化进程进行评估。,本论文对Aegean航空公司的定量和定性的分析结果表明, 数字化改革营销计划, 结合新兴RM措施, 能够增加航空公司直接分销渠道（网站&APP）的订单收益, 相较于中间分销渠道（GDS）。因此, Aegean航空公司DX进程同时也降低了成本和增加了收益。,DX模型航空业措施, 结合直接vs间接售票模式, 能够评估航空业数字化进程改进收益情况和产品定制化的有效工具, 这作为以客户为核心的商业战略和客户关系管理（eCRM）最潮流的趋势。

This study identifies the main actors in the Indian network neutrality case and explores the main formal and informal institutional arrangements that constrain and influence their agendas for traffic management practices (TMPs). The analysis applies institutional analysis to this subject matter. This study identifies the formal institutional arrangements such as licenses for ISPs and informal institutional arrangements manifesting in practices to block websites and applications, throttle this content, and engage in preferential treatment. 本研究识别了印度网络中立性的主要行动者，并探究了主要的正式及非正式制度安排，这些制度安排对其流量管理实践（TMPs）议程进行限制和影响。对该主题应用了制度分析。本研究识别了例如互联网服务供应商许可证等正式制度安排，以及一系列非正式制度安排，后者在实践中封锁网站和应用程序、关闭内容、并进行差异化处理。 Este estudio identifica a los principales actores en el caso de neutralidad de la red de la India y explora los principales arreglos institucionales formales e informales que limitan e influyen en sus agendas para las practicas de gestion del trafico (TMP). El analisis aplica el analisis institucional a esta tematica. Este estudio identifica los arreglos institucionales formales tales como licencias para ISP y arreglos institucionales informales que se manifiestan en practicas para bloquear sitios web y aplicaciones, acelerar este contenido y participar en un trato preferencial.

We tested hypotheses about moment-to-moment interpersonal influences on anger during couples' conflict, and the association of those anger dynamics with relationship satisfaction and intimate partner violence (IPV). Displayed anger was coded from laboratory observations of cohabiting couples (N = 197); experienced anger was assessed via a video-recall procedure. Credible, but variable, associations were found in which a person's anger display at one moment was linked to change in the partner's anger display and experience in the next moment. Women's anger experience was more strongly influenced by men's anger displays in couples with higher levels of IPV and couples with lower levels of relationship satisfaction. The displayed anger of men who perpetrated higher levels of IPV was more strongly influenced by women's anger displays. Overall, when individuals displayed higher intensity anger, partners reacted with increasingly angry feelings but decreasingly angry displays. Results suggest that anger dynamics relate to dyadic processes and that dynamics relate to important relationship outcomes. Dyadic anger dynamics might prove a worthy intervention target.Comprobamos hipótesis acerca de las influencias interpersonales en la ira de un momento a otro durante el conflicto de las parejas y la asociación de esas dinámicas de la ira con la satisfacción con la relación y la violencia de pareja. Se codificó la ira demostrada a partir de observaciones en laboratorio de parejas convivientes ((N = 197); la ira sufrida se evaluó mediante un procedimiento de videollamada. Se hallaron asociaciones creíbles, pero variables, en las cuales la demostración de ira de una persona en un momento estuvo ligada a un cambio en la demostración y la experiencia de ira del otro integrante de la pareja al momento siguiente. La experiencia de ira de las mujeres estuvo influenciada más marcadamente por las demostraciones de ira de los hombres en las parejas con niveles más altos de violencia de pareja y en las parejas con niveles más bajos de satisfacción en la relación. La ira demostrada de los hombres que ejercían niveles más altos de violencia de pareja estuvo influenciada más marcadamente por las demostraciones de ira de las mujeres. En general, cuando las personas demostraron una ira de mayor intensidad, sus parejas reaccionaron con sentimientos de ira cada vez mayores, pero con demostraciones de ira cada vez menores. Los resultados sugieren que la dinámica de la ira se relaciona con procesos diádicos y que esa dinámica se relaciona con importantes resultados para las relaciones. La dinámica diádica de la ira podría ser un objetivo valioso de intervención.我们测试了关于伴侣冲突中即时人际关系对愤怒情绪的影响，以及这些愤怒动态变化与关系满意度和亲密伴侣暴力(IPV)的关联的假设。本研究对197对同居夫妇的实验室观察数据进行解码; 外在的愤怒情绪经历过愤怒的人通过视频回忆过程进行评估。研究人员发现，一个人某一刻的愤怒表现与另一个人下一刻的愤怒表现和经历的变化存在关联，这种关联可信，但也存在变数。在IPV水平较高和关系满意度较低的伴侣中，男性的愤怒表现对女性的愤怒体验有更大的影响。IPV水平较高的男性表现出的愤怒受女性愤怒表现的影响更大。总的来说，当个体表现出更高强度的愤怒时，伴侣的愤怒情绪会越来越强烈，但愤怒的表现会越来越少。结果表明，愤怒动力学与二元过程相关，动力学与重要的关系结果相关。双方二者的愤怒动态过程可能被证明是一个有价值的干预目标。.

To investigate the factors affecting the quality of life among adults with comorbid serious mental illness and chronic diseases.Descriptive, cross-sectional study design.In total, 204 patients with serious mental illness were recruited from two hospitals. Self-reported data were collected using the Brief Psychiatric Rating Scale, Internalised Stigma of Mental Illness, Patient Activation Measure and brief version of the World Health Organization Quality of Life Instrument. Data were collected between July 2018 - January 2019. The structural equation model was applied to examine the associations among the study variables.Internalized stigma (β = -0.479, p = .002) had the greatest direct effect on quality of life, followed by patient activation (β = 0.238, p = .002), severity of comorbidities (β = -0.207, p = .002) and psychiatric symptoms (β = -0.186, p = .006). In addition, psychiatric symptoms directly influenced the severity of comorbidities, which in turn directly influenced internalized stigma and then in turn directly influenced patient activation and ultimately influenced quality of life.The relationship between internalized stigma and quality of life is significantly mediated by patient activation. This finding provides a theoretical basis for developing patient activation interventions for patients with comorbid mental and chronic diseases, which potentially improve the quality of life of this population.Multiple comorbidities cause impaired quality of life in patients with serious mental illnesses. We found that patient activation plays an important role in the management of chronic diseases for achieving more favourable quality of life, but this is negatively affected by internalized stigma. These findings can help mental health professionals develop tailored intervention strategies to enhance quality of life by promoting patient activation and reducing internalized stigma, psychiatric symptoms, and comorbidity severity in patients with comorbid serious mental illnesses and chronic diseases.目的: 探讨影响成年严重精神病兼慢性病患者生活质量的因素。 设计: 描述性横断面研究设计。 方法: 两所医院共计招募204名严重精神疾病患者。可通过简明精神病评定量表、精神病患者病耻感评估量表、患者激活措施和世界卫生组织生活质量量表的简要版本收集自我报告数据。数据收集时间为2018年7月至2019年1月。结构方程模型可用于检验不同变量之间的相关性。 结果: 内耻感 (β = −0.479, p = .002) 对生活质量的直接影响最大, 其次是患者激活度(β = 0.238, p = .002) 、并存病严重程度(β = −0.207, p = .002) 和精神症状 (β = −0.186, p = .006) 。此外, 精神症状直接影响并存病严重程度, 进而影响内耻感和患者的积极性, 最终影响其生活质量。 结论: 内耻感和生活质量的相关性可通过患者激活度来确定。这一发现为针对精神疾病兼慢性疾病患者的激活干预措施的开发提供理论基础, 可帮助改善相关人群的生活质量。 影响: 多种并存病可能导致严重精神疾病患者的生活质量下降。我们发现, 患者激活度在慢性病的治疗中起着重要的作用, 帮助提高患者的生活质量, 然而, 其可能受到内耻感的负面影响。此类发现可以帮助精神卫生专业人员制定针对性的干预策略, 提高患者的积极性, 减少严重精神疾病兼慢性病患者的内耻感、精神症状和并存病严重程度, 提高其生活质量。.

To assess the effects of upright positions on maternal outcomes for women without epidural analgesia in comparison with recumbent positions during the second stage of labour.Upright positions have many physiological advantages. The underlying benefits and risks of upright positions during the second stage of labour have been reported in many studies but the results are divergent.A meta-analysis of randomized controlled trials.The Cochrane Library, PubMed, Embase, CINAHL and ProQuest databases were systematically searched from inception to 17 June 2019.We conducted the quality appraisal using the Cochrane Collaboration's tool and performed meta-analyses using the Review Manager 5.3 software. The primary outcomes were instrumental vaginal delivery and the duration of the second stage of labour.Overall, 12 studies including 4,314 women were included. Upright positions significantly decreased the rate of instrumental vaginal delivery (risk ratio [RR] = 0.74, 95% CI 0.59-0.93), shortened the active pushing phase (mean difference [MD] = -8.16 min, 95% CI -16.29 to -0.02), decreased the rate of severe perineal trauma (RR = 0.35, 95% CI 0.14-0.87) and episiotomy (RR = 0.52, 95% CI 0.29-0.92), but significantly increased the rate of second-degree perineal trauma (RR = 1.45, 95% CI 1.10-1.90). However, there was no significant difference in the duration of the second stage of labour or postpartum haemorrhage.Upright positions are beneficial for improving maternal outcomes. Several results should be considered with caution. Researchers need to clarify the definition of upright positions and conduct large, robust studies in the future to provide stronger evidence.This meta-analysis explores a crucial issue in intrapartum care and clarifies the benefits and possible risks of upright positions in the second stage of labour. Midwives and obstetricians are encouraged to apply upright positions depending on women's preferences and labour progress but should take measures to prevent perineal trauma.目的: 评估在第二产程中,与卧位相比,直立体位对未使用硬膜外镇痛的产妇的预后的影响。 背景: 从生理角度讲,直立体位具有许多优势。许多研究报告了第二产程期间直立体位的基本益处和风险,但结果却不尽相同。 设计: 随机对照试验的荟萃分析。 数据来源: 从各数据库成立至2019年6月17日,对Cochrane Library、PubMed、Embase、CINAHL和ProQuest等数据库进行了系统化检索。 审查方法: 使用科克伦协作网的工具进行质量评价,并使用Review Manager 5.3软件进行荟萃分析。主要预后指标是器械性阴道分娩和第二产程的持续时间。 结果: 总的来说,包括了12项研究,涉及4314名妇女。直立体位显著降低了器械性阴道分娩率(风险比[RR]=0.74,95%置信区间0.59-0.93),缩短了主动推宫阶段(平均差 [MD]=−8.16分钟, 95%置信区间−16.29 to −0.02),降低了严重会阴创伤发生率(RR=0.35, 95%置信区间0.14-0.87)和会阴切开术(RR=0.52, 95%置信区间0.29-0.92),但显著增加了二度会阴创伤的发生率(RR=1.45, 95%置信区间.10-1.90)。但在第二产程的持续时间或产后出血方面没有显著差异。 结论: 直立位有利于改善孕产妇预后。有几项结果应予以谨慎考虑。研究人员需要明确直立体位的定义,并在未来进行大规模、稳健的研究,以提供更有力的证据。 影响: 本荟萃分析探讨了产时护理中的一个关键问题,并阐明了直立体位在第二产程中的益处和可能存在的风险。鼓励助产士和产科医生根据产妇的喜好和产程进展采用直立体位,但应采取措施防止会阴创伤。.

This study aims to investigate the potential association of peripheral inflammatory blood cell parameters with the incidence and progression of chronic kidney disease (CKD) in patients with diabetes.The cross-sectional study included 1192 subjects with diabetes derived from one center. The cohort study included 2060 subjects with diabetes derived from another two centers followed up for 4 years. Logistic regression and Cox proportional hazards models were used to evaluate the association of peripheral inflammatory blood cell with CKD.In the cross-sectional study, neutrophil count performed best as an independent risk factor for CKD (odds ratio 2.556 [95% confidence interval 1.111, 5.879]) even after 1:1 case-control matching for age, gender, history of high blood pressure and duration of diabetes. Spline regression revealed a significant linear association of CKD incidence with continuous neutrophil count in excess of 3.6 × 10This study suggested that neutrophil count is an independent risk factor for progression of CKD in patients with diabetes.背景: 本研究旨在探讨糖尿病人中外周血炎性细胞参数与慢性肾脏疾病(CKD)的发生和发展之间的潜在相关性。 方法: 以1192名来自同一研究中心的受试者作为横断面研究。来自另外两个中心的2060名受试者随访4年，进入队列研究。采用Logistic回归和COX比例风险模型评价外周血炎性细胞与CKD的相关性。 结果: 在横断面研究中，即使在年龄、性别、高血压病史和糖尿病病程进行1:1病例对照匹配后，中性粒细胞计数仍然是CKD的最相关的独立危险因素(OR 2.556[95%CI 1.111，5.879])。样条回归显示CKD发病率与中性粒细胞计数持续超过3.6×10

Prior research indicates that couples who cope with chronic illness from a relational "we" orientation experience more positive outcomes than couples that cope individually; however, little prior research identifies clinical processes that promote reciprocity or how societal gender processes are involved. This grounded theory analysis of 25 videotaped therapy sessions with six heterosexual couples coping with chronic liver disease (LD) used a feminist-informed relational lens to focus on the clinical processes involved in shifting from an individual to a relational orientation. Findings identified three contextual barriers to attaining a "we orientation": (a) autonomy discourse, (b) illness-related power, and (c) gendered power. Analysis detailed therapist actions that decreased the impact of barriers to reciprocity and fostered relational coping. Clinical implications attend to complex intersections among gender, caregiving, and contextual barriers to reciprocity.Investigaciones anteriores indican que las parejas que hacen frente a una enfermedad crónica desde una orientación relacional basada en el “nosotros” tienen resultados más positivos que las parejas que la enfrentan individualmente; sin embargo, existen escasas investigaciones previas que identifiquen los procesos clínicos que promueven la reciprocidad o la manera en la que están implicados los procesos de género social. Este análisis de teoría fundamentada de 25 sesiones de terapia videograbadas con seis parejas heterosexuales que enfrentan una enfermedad hepática crónica utilizó una óptica relacional fundamentada en el feminismo para centrarse en los procesos clínicos relacionados con el paso de una orientación individual a una relacional. Los hallazgos identificaron tres obstáculos contextuales para lograr una “orientación basada en el nosotros”: (a) el discurso de autonomía, (b) el poder relacionado con la enfermedad, y (c) el poder asociado al género. El análisis detalló las medidas del terapeuta que redujeron el efecto de los obstáculos para la reciprocidad y fomentaron el afrontamiento relacional. Las implicancias clínicas tratan de las intersecciones complejas entre el género, el cuidado y los obstáculos contextuales para la reciprocidad.以往的研究表明，当伴侣们从“我们”关系导向应对慢性病时，比起伴侣们一方单独应对疾病，其治疗效果要更趋向良性; 然而，以前的研究几乎没有确定促进相互关系的临床过程或社会性别过程是如何参与其中的。本研究对6对患有慢性肝病的异性恋伴侣的25次治疗过程进行录像，对影像资料进行了扎根理论分析，使用女权主义理论指导下的关系视角，聚焦于治疗过程中从单个个体转移到相互关系方向的变化。调查结果确定了三个不利于实现“我们导向”情境障碍：（a）关于自我自主的话语，（b）与疾病有关的权力，和（c）性别权力。研究对治疗师所作的旨在减少对导向相互关系的障碍产生的影响的行为，以及促进共同关系应对的做法的行为进行了细致地分析。本研究的临床意义在于认识到参与过程中的涉及性别、护理和具体情境造成的相互作用障碍之间的复杂关系。.

To examine whether the work-life interface (through work-family conflict and overall work-life balance) moderates the relationship between work ability and workplace demands and resources.This study used a cross-sectional survey design to collect data from 426 employees working in residential aged care.A paper-based questionnaire was distributed to all permanent and casual employees at eight aged care facilities in Melbourne, Australia, between June - September 2013. Moderation analyses were conducted using PROCESS v. 2.13 in SPSS v. 22.As expected, workplace demands and resources directly influenced workers' work ability. In addition, moderate-to-high levels of work-family conflict and low-to-moderate levels of satisfaction with work-life balance combined interactively with particular workplace demands and resources (relationships with management, physical demands, and safety climate) to reduce work ability.This study advances understanding of how work-life balance and work-life conflict can influence work ability levels and shows that addressing the work-life interface may be a legitimate means to improve work ability, potentially leading to continued workforce participation.Staff retention in the residential aged care sector needs to be addressed. One possible means of achieving this is through improving work ability. This study expanded knowledge of how the work-life interface may influence work ability. The research demonstrated that relationships between work ability and particular workplace demands and resources were moderated by the work-life interface. This finding has implications for how human resources managers of residential aged care facilities may improve workforce retention-through facilitating employees to manage the work-life interface better.目的: 研究工作-生活界面(通过工作-家庭冲突和整体工作-生活平衡)是否调节工作能力与工作场所需求和资源之间的关系。 设计: 本研究采用横断面调查设计,收集了426名在养老院工作的员工数据。 方法: 2013年6月至9月,我们向澳大利亚墨尔本8家老年护理机构的所有长期员工和临时工发放了一份纸质问卷。采用SPSS第22节第2.13节的过程进行适度分析。 结果/发现: 正如所料,工作场所的需求和资源直接影响着员工的工作能力。此外,中等至高水平的工作-家庭冲突和较低至中等水平的工作-生活平衡满意度与特定的工作场所需求和资源(与管理、物质需求和安全氛围的关系)相互作用,以降低工作能力。 结论: 本研究增进了对工作-生活平衡和工作-生活冲突如何影响工作能力水平的理解,并表明处理工作-生活界面可能是提高工作能力的一种合理方法,潜在地引起持续的劳动力参与。 影响: 需要解决居住养老部门的工作人员留用问题。实现这一目标的一个可能途径是提高工作能力。本研究扩展了工作-生活界面如何影响工作能力的知识。研究表明,工作能力与特定工作场所需求和资源之间的关系受工作-生活界面的调节。这一发现对老年护理机构的人力资源管理人员如何通过促进员工更好地管理工作-生活界面来提高员工保留率具有启示意义。.

Drawing on a sample of 520 negative reviews posted on TripAdvisor against all five-star hotels operating in Petra, Jordan, the purpose of this paper is to evaluate the response of luxury hotels to negative online reviews by considering the Response Rate (RR), the Response Time (RT) and the Response Content (RC).,A deductive content analysis was used on hotels’ managerial responses. Based on the literature review, a four-construct scheme was identified to guide the analysis including Appreciation; Apology; Explanation; and Incentive. The managerial responses were carefully read and manually coded based on the four-construct scheme. The time between the review posting date and the date of the managerial response was also recorded. Luxury hotel managers were also surveyed to obtain insights into their perceptions and practices with respect to online reputation management.,The findings call into question luxury hotels’ awareness of the harmful impact of negative online reviews. Specifically, the findings suggest that less than half of the negative reviews received a managerial response, and that more than half of these were standardized and did not refer to the issues raised in the reviews. The low response rate coupled with the hotel managers’ consensus on the importance of answering all online reviews indicates inconsistency between hotel managers’ perceptions and practices with regard to online reputation management.,The paper adds to the ongoing debate on reputation management in the hospitality industry by considering the managerial response to negative online reviews. The paper discusses several managerial implications for hotel managers as well as avenues for future research.,本论文以TripAdvisor网站上520条关于约翰佩特拉古城五星级酒店的负面评论为样本, 分析豪华酒店如何应对网上负面评论, 具体评估变量包括反应率（RR）,反应时间（RT）,以及应对内容(RC)。,本论文采用由繁入减的方法来文本分析酒店经理应对反馈内容。结合文献综述, 本论文共确立四个变量：（1）感谢；（2）道歉；（3）解释；以及（4）补偿。经理回复内容经过了研读和手动编码等过程进行分析。评论刊登和经理反馈时间差也经过审阅分析。此外, 豪华酒店经理还接受了问卷调查来获得他们关于在线名誉管理的意见和处理措施。,本论文结果呼吁豪华酒店对于网上负面评论的严重影响的重视。其中, 研究结果表明, 不足一半的负面评论获得了经理回复, 而且, 一半以上的回复还是标准回答, 并没有涉及评论中提出的问题。低回复率以及酒店经理对于回复所有网上评论的统一认识表明, 酒店经理对于网上名誉管理的认知和措施存在于不一致性。,本论文主要研究了经理应对在线负面评论的态度和措施, 其研究结果对于酒店业名誉管理方面一直以来存在的争论提供了科学检验。本论文讨论了多个酒店经理人管理理念以及提供了未来科研方向。

Improving the process of care may effectively improve the quality of medical care and increase patient satisfaction. An investigation found that the process of care used in our unit was imperfect, resulting in a low preoperative enrollment rate of case managers, overly long patient waiting times for ward assignment, insufficient pre-operative knowledge, and high cancellation rates for routine operations.The aim of this project was to review the overall process of care using the concept of patient flow to improve and formulate countermeasures to improve quality of care.To improve the process of care, the corresponding countermeasures were formulated. 1. Set criteria for enrollment for orthopedic case managers to increase the preoperative enrollment rate; 2. Set up a specialized arthroplasty care area for central case management to reduce the time patients need to wait for the ward; and 3. Improve patient compliance with preoperative education and reduce the operation cancellation rate by distributing patient education pamphlets, filming videos of pre-operative instructions, facilitating home environment preparation, and providing education on sterilization baths.After implementation of the countermeasures, the preoperative case manager enrollment rate increased from 27.8% to 84.6%; the average ward wait time for patients reduced from 73 to 41 minutes; compliance with patient education increased from 83.0% to 100%; and the operation cancellation rate reduced from 11.1% to 0%.This project used the concept of patient flow to review the care process used for total knee arthroplasty. This improvement strategy may be used to standardize care processes and improve the quality of medical care provided.以病人流概念改善人工膝關節置換術照護流程.適當的流程改善可以有效提升醫療照護品質亦可增加病人滿意度。現況調查發現照護流程不完善導致個管師術前收案率低、病人入住時間過長、術前相關衛教認知不足、常規手術取消率高。.藉由病人流概念檢視整體照護流程進行改善及對策擬定，提升照護品質。.為提供完善照護流程，故擬定因應對策：(1)制定骨科個管師標準收案流程，以提高術前收案率；(2)建置關節置換專區將病人集中管理照護，以降低病人入住病室時間；(3)製作膝望護照、拍攝術前須知及居家環境準備影片和拍攝殺菌澡衛教影片，以提升病人術前衛教遵從性及降低手術排程取消率。.經改善後，個管師術前收案完成率由27.8%提升至84.6%；入住病室時間由73分鐘縮短至41分鐘；衛教遵從率由83.0%提升至100%；手術排程取消率由11.1%降至0%。.本專案運用病人流概念檢視人工膝關節置換術照護流程，藉由專案改善措施落實照護流程標準化，進而提升整體醫療照護品質。.

Intra-arterial thrombectomy (IAT) is a novel surgery that may restore cerebral blood flow in patients with ischemic stroke and lower the risks of permanent brain damage and disability. Because the process of preoperative preparation for IAT is complicated, error rates for this process have been reported in previous studies to be as high as 100%. Although these errors did not result in serious damage to patients, the risk to patient safety remains. Therefore, reducing the error rate for IAT preoperative preparation is necessary to improve patient safety.To reduce the rate of IAT preoperative preparation error in an emergency room.This project applied healthcare failure mode and effect analysis (HFMEA) to evaluate the potential risks of IAT preoperative preparation in an emergency room. Based on the resultant hazard score, critical preventive measures were adopted, including creating a quick response code consent form, designing order packages, developing a checklist form, modifying stroke operating procedures and policies, planning suitable education content for staffs, developing criteria for evaluating preoperative preparation procedures, and installing vital signs equipment.After implementation of these measures, the hazard scores of 13 out of the 16 potential failure causes decreased to8, and the progress rate was 81.3%. The follow-up error rate for preoperative preparation was 0% in October 2019, which fulfilled the goal of this project.Preoperative preparation for IAT is complicated and time-consuming. In this project, HFMEA was introduced to ensure that preoperative preparation was accomplished in a complete and timely manner. Based on the results, after implementation, preparation work was effectively completed and operations were performed on schedule. Other hospitals may consider using this tool to evaluate potential risks to patient safety and to develop solutions to improve the quality of healthcare processes.運用醫療失效模式與效應分析降低急診室動脈內取栓術術前準備缺失率.動脈內取栓術為治療缺血性腦中風病人並幫助血管再灌流的新穎手術方式；能減少腦損傷和失能的風險。鑑於本單位動脈內取栓術術前準備過程複雜造成缺失率高達100%；雖皆為幾近錯失（near-miss），但仍有病人安全之疑慮，因此選用醫療失效模式與效應分析（healthcare failure mode and effects analysis, HFMEA）檢視單位動脈內取栓術術前準備流程，找出高風險因子，執行預防措施及因應策略，確保病人安全。.降低急診室動脈內取栓術術前準備缺失率。.本專案依照HFMEA之五步驟進行，執行日期2019年4月1日–10月31日，依潛在失效原因進行危害指數計算與決策樹分析並擬定行動方案：製作同意書quick response code、設計醫令套餐、制定查核表、修訂同意書與程序書、舉辦在職教育、建立稽核制度與增購設備。.原16項潛在失效原因的有13項危害指數均降低至8分以下進步率為81.3%；持續追蹤本單位2019年12月，動脈取栓術術前準備缺失率為0%，顯示有達成專案之目的。.本專案運用HFMEA建構動脈內取栓術執行流程安全策略，執行的結果是完備術前準備過程，且病人沒有發生手術延遲。建議國內各醫院能針對病人安全之高風險流程進行檢測及改善，以提升病人的照護品質。.

Cataract is a global disease that may cause blindness. Due to the slow pace of disease progression, patients often presume incorrectly that their blurred vision is caused by excessive fatigue or lack of sleep. In addition to their role in causing blindness, cataracts that are diagnosed late into their progression are more difficult to treat with corrective surgery. Furthermore, many older individuals believe incorrectly that declines in vision are part of the natural course of aging and accept these declines as inevitable. Reduced vision has a significant and negative effect on quality of life. Although aging is one of the main causes of cataracts, other major factors include common chronic diseases and the side effects of drugs. In addition, lifestyle factors such as diet, activity, and environmental exposure to ultraviolet rays and radiation are factors in cataract development. Surgery is the only treatment for cataracts currently available. Healthcare professionals not only consider a patient's background but also whether surgery may promote quality of life. While preoperative evaluation requires a holistic and comprehensive approach, postoperative care is also important to the overall success of cataract surgery. For example, instructions in topical-drop application, wound assessment, and symptoms of comorbidities are crucial for patients. Therefore, a critical literature review was used in this article to establish a strategy for the holistic evaluation of and perioperative nursing care and prevention strategies for cataracts. In addition, recommendations for the comprehensive assessment of and nursing care for patients with cataracts are provided to healthcare professionals article in hopes of improving the quality of care provided to patients with cataracts.白內障完整評估治療與照護趨勢.白內障，一個可能導致眼盲的全球性疾病，由於疾病過程進展緩慢，使得患者常誤以為視力模糊，僅是過度疲勞或睡眠不足而延誤就醫，也增加了診斷白內障後手術的困難度。有些高齡者則誤以為視力下降，本是老化的一部分而被動接受，減退的視力卻對其生活品質有重大的負面影響。老化雖是白內障的主因之一，但常見的慢性疾病，或藥物副作用亦是產生白內障的推手；此外，個人生活型態，如飲食、活動量及環境，如紫外線、輻射皆可促成白內障的發生。手術是目前唯一治療白內障的方法，醫護人員不單只考慮病人的背景，也要能促進生活品質。術前的評估除了需要整體性、全面性的考量，術後的照護亦是重點，如點藥方法、觀察傷口及合併症的徵象皆為提供患者的必要訊息。有鑑於此，本文藉由文獻查證統整與白內障相關之評估重點、手術全期護理照護及預防策略，提供臨床醫護人員在白內障患者的全面性評估與照護之參考，希望進而提升白內障患者照護品質。.

Da Vinci robotic system is currently widely used in thoracic surgery. The ports employment and procedures vary in different medical center in China. Usually, a small incision was used for assistant.Based on clinical practice, we summarized domestic and foreign experience, combined with the characteristics of the Chinese body anatomy, employ portal technique and artificial pneumothorax, summarized a set of simplified and easier surgical method.Port-only artificial pneumothorax robot-assisted lobectomy has further improvement in anatomical safety, hemostatic effect and aesthetic appearance of the wound.This study optimizes the procedure of port-only artificial pneumothorax robot-assisted lobectomy in order to serve lung cancer patients better.【中文题目：全孔道（port-only）人工气胸下机器人辅助肺叶切除术】 【中文摘要：背景与目的 达芬奇机器人手术操作系统目前在胸外科得到了广泛的应用，国内不同中心采用的建立通道方式及操作流程，不同辅助操作孔多采用小切口的方式。方法 基于大量临床实践的基础上，我们在实践中总结国内、外经验，并结合国人体型特点，对机器人辅助肺叶切除术的切口及操作流程进行了改进并实践出一套更加简化易行的手术方法。结果 全孔道（port-only）人工气胸下机器人辅助肺叶切除术在术中解剖安全性，止血效果和伤口美观性方面，都有进一步的提升。结论 本研究对全孔道人工气胸机器人辅助肺叶切除的流程加以优化，以期为肺癌患者更好地服务。】 【中文关键词：肺癌；机器人辅助胸外科；全孔道；优化】.

Open-heart surgery and conservative medical treatments have been the traditional, mainstay treatments for patients with severe mitral regurgitation (MR). Transcatheter edge-to-edge mitral repair is a novel technique. Using the transcatheter approach allows delivery of the clip into the left ventricle and the clipping of the orifice of the MR. The heart failure symptoms and outcomes of patients improve after this procedure. Compared to open-heart surgery, the mitral clip achieves similar MR reduction results with a significantly lower rate of complications. Since 2016, MitraClip has been available for clinical use in Taiwan. The aim of this report is to introduce this new treatment with a focus on nursing care in order to provide a reference for clinical care.重度二尖瓣逆流治療的新技術—經導管二尖瓣修補術及護理.重度二尖瓣逆流的治療，以往是以傳統開心手術及保守藥物治療為主，而經導管二尖瓣膜修補術則是一項新發展的技術，主要是利用心導管的方式，遞送二尖瓣膜夾來夾合閉鎖不全的二尖瓣，以改善二尖瓣逆流造成的心臟衰竭症狀與預後。國外已有許多研究證明，此介入性治療方式與傳統二尖瓣開心手術比較，對於二尖瓣膜逆流的病患有較低的手術相關併發症發生比率，亦可有效改善血液逆流的程度，進而改善心臟衰竭的嚴重度，是二尖瓣逆流達中重度以上手術高風險患者的一項新的選擇，國內於2016年引入此項新治療的方式，本文主要為簡介此項新治療方式及彙整護理照顧重點，以提供臨床照顧參考。.

Eddy covariance (EC) time-series data obtained from flux towers are noisy due to both stochastic atmospheric turbulence and deterministic processes, and no standard data-denoising protocols exist for them. The potential of six temporal artificial neural networks (ANNs) augmented with and without three orthogonal wavelet functions was tested for predicting net ecosystem exchange of carbon dioxide (CO2) based on a long-term EC data set for a temperate peatland. Multiple comparisons were made of (1) temporal ANNs with and without discrete wavelet transform (DWT) denoising; (2) denoising with the orthogonal wavelet families of Daubechies, Coiflet, and Symmlet; (3) different decomposition levels; (4) time-delay neural network, time-lag recurrent network, and recurrent neural network; (5) online learning versus batch learning algorithms; and (6) diel, diurnal, and nocturnal periods. The coefficient of determination, root mean square error, and mean absolute error performance metrics were used for multiple comparisons based on training, cross-validation, and independent validation of the temporal ANNs as a function of 24 explanatory variables contained in an EC data set. Integration of the temporal ANNs and DWT denoising provided more accurate and precise estimates of net ecosystem CO2 exchange. Los datos de series de tiempo de covarianza tipo Eddy (EC) obtenidos de torres de flujo (flux-towers) contienen ruido debido tanto a la turbulencia atmosferica estocastica como a los procesos deterministicos modelados. A pesar de esto, no existen protocolos estandarizados para la eliminacion de ruido en este tipo de datos. El estudio presente pone a prueba el potencial de seis redes neuronales artificiales temporales (ANN) a las que se les anade con (y remueve) tres funciones de transformada de ondicula (wavelets) ortogonales con el fin de predecir el intercambio neto ecosistemico (NEE) de dioxido de carbono (CO2) usando un conjunto de datos EC de largo plazo correspondientes a una turbera ubicada en zona templada. Se realizaron multiples comparaciones de (1) las ANN temporales con y sin transformacion wavelet discreta (DWT) para la remocion del ruido; (2) la eliminacion de ruido usando las familias de wavelets ortogonales de tipo Daubechies, Coiflet y Symmlet; (3) diferentes niveles de descomposicion; (4) redes neuronales con retraso temporal (time-delay) (TDNN ), con retardo (lag) de red recurrente (TLRN), y la red neuronal recurrente (RNN); (5) con aprendizaje en linea versus algoritmos de aprendizaje en lote (batch); y, (6) para ciclos circadianos, diurnos, y nocturnos. Para comparar los rendimientos de cada metodo se calcularon el coeficiente de determinacion, el error cuadratico medio (RMSE), y la media de error absoluto (MAE), provenientes de los datos de validacion cruzada, calibracion y validacion independiente de los ANN temporales y en funcion de 24 variables explicativas de los datos EC. Los autores concluyen que la integracion de los ANN temporales con la remocion de ruido tipo wavelet proporciona estimaciones mas exactas y precisas del intercambio neto ecosistemico de CO2. 受随机大气湍流和确定性过程扰动的影响，利用涡度相关法从通量塔中测定的时间序列数据是高噪音的，目前仍缺乏标准的数据去噪方案。本文基于一个温带泥炭地长期观测的EC数据集，测试了六个潜在的时态人工神经网络(ANNs)，以及其在包含或者不包含三个正交的小波函数增强的条件下对二氧化碳（CO2）的净生态系统交换（NEE）的预测能力。比较试验分为以下几组：(1)使用或不使用离散小波变换（DWT）去噪的时态ANNs；(2)采用Daubechies, Coiflet和 Symmlet正交小波族去噪；(3)不同的小波分解层级；(4)时间延滞神经网络（TDNN）、时间滞后递归网络（TLRN）和递归神经网络(RNN)；(5)在线学习与批量学习算法；(6)昼夜、白天和夜间三种周期。将时态ANNs作为EC数据集中24个解释变量的函数，运用决定系数、均方根误差(RMSE)和平均绝对误差(MAE)指标对其训练、交叉验证和独立验证过程进行多重比较测试。结果显示，集成时态ANNs和DWT去噪可以提供更为准确的净生态系统CO2交换量的估计。

As social harmony and stability become increasingly important to the Chinese policymakers, how to use government spending to help the unemployed and needy population becomes a key task. Unlike many western countries, China pursues a highly decentralized policy in social safety net and employment assistance spending. This paper explores the advantages and challenges of this fiscal arrangement, and uses data of about 330 Chinese cities between 2007 and 2010 to analyze how this spending evolved during the ups and downs in the national economy. Based on various descriptive analyses and a hierarchical model, our results show that the Chinese government has indeed increased social safety net spending significantly over time. However, contrary to our prior expectation, cities with higher gross regional products per capita and cities in the richer coastal provinces spend less per non-employed person, after controlling for the non-employment population ratio in the cities. In general, the share of SSNEA budget in the total general budget has remained relatively stable despite economic ups and downs. From this perspective, China seems to be quite successful in maintaining a balanced approach to social assistance and has avoided the over-expansion of welfare and pension spending that is being witnessed in many western countries. 随着中国政府决策者对社会和谐和稳定越来越重视，如何使用政府财政支出来帮助失业和贫困人群已成为一项关键性任务。与许多西方国家不同，中国在社会保障和就业援助支出方面执行高度分散的政策。本文对这种财政制度的优点和挑战进行了探讨，并使用2007年到2010年来自约400个中国城市的数据对中国经济周期中的社会保障和就业援助支出的演变过程进行了分析。基于多项描述性分析和分层模式，我们的研究结果显示中国政府这些年来确实显著提高了社会保障支出水平。但是，与我们之前的预期相反的是，在对城市中的失业人口比例进行对比后发现，区域人均产值较高的城市和较为富裕的沿海城市的失业人口平均支出却较低。总的来说，尽管经济有跌宕起伏，但是中国在社会保障和就业援助方面的财政预算占财政总预算中的比例却保持了相对稳定。从这个角度来看，中国在维持平衡的社会救助政策方面还是相当成功的，避免了许多西方国家出现的福利和养老金支出过度扩张所带来的问题。

文学世家历史还原的过程,也是一个逻辑建构的过程。以政治文化制度变革为核 心动力,通过家族史与文学史演变的双重梳理,可以对中国通代文学世家发展演变历 程进行历史还原,即前中后三大时段三重形态的相互衔接与有序推进: 两汉至南北朝 “经学—文学世家”与“门阀—文学世家”双重形态的衔接与演进; 隋唐时期“门 阀—文学世家”与“科宦—文学世家”混合形态的交替与演进; 两宋至明清“科宦— 文学世家”主流形态的承变与演进。在上述主体形态之外,尚有其他类型文学世家的 多元存在。文学世家史学术范式的建构,需要通过特定个体、时代、区域以及通代文 学世家史四个层级的链接而融合为有机整体。 关键词: 文学世家 历史还原 逻辑建构 The process of reconstructing the history of the literary family is also a process of logical construction. By focusing on the transformation of political and cultural institutions and sorting through the historical evolution both of literature and of distinguished families, we can describe the historical evolution of the literary family in Chinese dynastic history, that is, the succession and the orderly progress of its three forms over three periods. The first period from the Han Dynasty to the Northern and Southern Dynasties saw the emergence of “literary families of classical scholars,” and their evolutionary successors, “literary families with hereditary power.” In the second period of Sui and Tang ...

The newest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) has just been published. The DSM is an essential tool for mental health professionals and clinicians to diagnose patient conditions and conduct post-diagnosis communications with patients. Further, hospitals, clinics, and insurance companies in the U.S. generally require a DSM diagnosis for all patients treated. The DSM may be used in clinical settings as well as in research settings for patient categorization purposes. Studies on specific disorders often recruit patients based on symptoms criteria listed in the DSM. However, the latest version of the DSM has generated controversy due to various issues and caused disappointment among some researchers and clinicians. In this paper, the authors conduct a comprehensive review of the development of the DSM.精神醫學診斷之變遷最新版的精神疾病診斷準則（diagnostic and statistical manual-five edition, DSM-V）前幾個月由美國精神醫學學會正式出版，雖中文翻譯版尚未出版，但這最新的版本仍然引起盼望多年的研究者與臨床工作者許多的討論與爭議。因為不論臨床實用如何，似乎都與研究所需，有一段距離；研究者強調研究工具的準確性，但臨床工作者著重於方便與實用。精神疾病診斷準則的發展源於第二次世界大戰後，美國有鑑於戰場出現戰鬥衰竭症及往後的退伍軍人之創傷症候群，催生了精神疾病診斷分類的發展。自1951年至今已經過數次改版，也已被學界及臨床廣泛接受與使用，美國的保險公司也接受以此診斷所請領的保險給付。隨著最新版（DSM-V）的出刊，勢必使臨床工作者與研究者面臨新的適應。本文將從此準則的緣起，對其演進歷程進行回顧與評論。

Sepsis is a systemic inflammation caused by severe infection. It is a condition that is life-threatening, progresses rapidly, and affects multiple system functions. An evidence-based medical sepsis bundles model has been used for sepsis care in clinic practice. Therefore, a holistic nursing care protocol for patients with sepsis is needed to improve medical outcomes. This case study describes a nursing experience using Levine's Conservation Model to care for a patient with sepsis. Data were collected using physical assessment, medical chart reviews, written communications with the patient, interviews patient family members, and observing the patient during intensive care hospitalization from June 10th, 2011 through July 5th, 2011. Levin's Conservation Model, used as the nursing guideline, successfully identified patient issues including failure to conserve energy, structural, personal and social integrity. Interventions included: (1) sepsis bundles and early goal directed therapy to reduce patient energy expenditure; (2) prevention of infection to maintain structural function; and (3) enhancement of self-esteem, privacy, family cohesion, and social activities to maintaining personal and social integrity functions. The interventions helped the case adapt successfully to the sepsis-related imbalance. This case report provides a valuable nursing care experience as a reference for similar sepsis cases in the future.運用Levine保存模式照護一位敗血症個案之護理經驗敗血症是因感染而引起的全身性發炎反應，病程進展快速，影響全身器官功能，進而造成個體生命威脅。目前以實證基礎之敗血症組合照護（sepsis bundles），配合強調整體性評估及全人照護之護理模式，應可改善敗血症病人照護成效。筆者利用Levine保存模式照護一位敗血症個案，照護期間自2011年6月10日至2011年7月5日，透過身體評估、病歷查閱、病人筆談、家屬及訪客會談與觀察方式收集相關資料，並根據保存模式進行護理評估，發現個案無法成功調適其能量、結構、個人完整及社會完整性等四個保存原則。護理過程中，藉由提供敗血症組合照護模式及初步復甦措施，協助個案獲得能量的保存；以感染的預防，維持其結構的完整；維護自尊、隱私與維持家庭及社會活動，保存其個人及社會功能的完整，最後成功調適因敗血症造成的整體性失衡。期望此保存模式運用的照護經驗分享，可提供護理人員日後於臨床照護敗血症個案之參考。