Thursday, February 28, 2008

Utah House Honors Hinckley and His Family




House honors Hinckley and his family

By Nicole Warburton
Deseret Morning News
Published: February 26, 2008
Members of the Utah House of Representatives passed a resolution Tuesday, honoring the life of President Gordon B. Hinckley, the late leader of The Church of Jesus Christ of Latter-day Saints.

President Hinckley died in January of causes incident to age. He was 97.

Before legislators approved the resolution, HCR6, several spoke about their personal experiences with the LDS prophet, calling him a gentle man with a sense of humor. Rep. Mike Morley, R-Spanish Fork, said President Hinckley was a "builder.

"President Hinckley had a tremendous influence, not only on the church, but in Salt Lake City, Utah, the United States and the world," Morley said. "President Hinckley certainly was the consummate builder, always building those around him and making them better — building the world to be a better place."

Rep. Phil Riesen, D-Salt Lake, said that Hinckley was a unique and irreplaceable man.

"We will likely not see someone of President Hinckley's stature again in our lifetimes," Riesen said. "I will miss him very much."

Several members of President Hinckley's family were attendance in the House Chamber when the resolution was passed, including his son, Clark Hinckley. They were given a standing ovation as they left, smiling and acknowledging members of the House.

"What a grand opportunity it is just to pause and reflect," said House Majority Leader Dave Clark, R-Santa Clara. "I think many of our lives have been touched in many ways for the positive."

President Hinckley served for 12 years as president of the LDS church. During his tenure, membership of the church grew from 9 million to over 13 million members worldwide, and President Hinckley also dedicated more temples than any other of his predacessors.

In the week after his death, members of the LDS church sustained a new prophet, President Thomas S. Monson, who served as President Hinckley's counselor in the LDS First Presidency.

President Monson, 80, is one of the youngest men in recent years to serve as the LDS prophet.


E-mail: nwarburton@desnews.com

Wednesday, February 27, 2008

The Love of God: Suffering Tribulation in the Redeemer's Name

The Love of God:
Suffering Tribulation
in the Redeemer's Name

GENE R. COOK


Gene R. Cook was a member of the First Quorum of the Seventy
of The Church of Jesus Christ of Latter-day Saints
when this devotional address was delivered on 1 February 2005.

� Intellectual Reserve, Inc. All rights reserved.

Complete volumes of Speeches are available wherever LDS books are sold.

For further information contact:
Speeches, 218 University Press Building, Provo, Utah 84602.
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What a privilege it is to be here at Brigham Young University and to be able to address all of you wonderful students. Whether you know it or not, you convey a great spirit and are having and will have a great impact upon the world. As a result of the training you receive here and your personal righteousness, you truly are, as Jesus said, a �light . . . on [a] hill� (Matthew 5:14).

Sister Cook and I have been privileged to have all of our children attend BYU�six of whom have graduated and two others who are preparing to do so. At least they hope so. I hope we are all very appreciative of the First Presidency, who feel strongly about education and provide such a wonderful institution, even the Lord�s university.

Loving God Even in the Face of One�s Trials

This morning I would like to address a topic entitled �The Love of God: Suffering Tribulation in the Redeemer�s Name.� Above all else, I desire that you know that God loves you. He loves all of His children across the world, and in spite of the very difficult problems being encountered worldwide these days, as well as in your individual lives, the love of God permeates all.

During a terrible war between the Lamanites and the Nephites where thousands were dying on both sides, Alma recorded:

Many had become hardened, because of the exceedingly great length of the war; and many were softened because of their afflictions, insomuch that they did humble themselves before God, even in the depth of humility. [Alma 62:41]

Our trials can either end up hardening our heart or humbling us. How true the saying that suffering in life is inevitable, but misery is of our own making. In other words, because of the plan that we all agreed upon in the premortal life, we are going to suffer, whether we want to or not. However, if you can find how to suffer that tribulation in the Redeemer�s name, you will bear it well and perhaps even do it with an understanding, happy heart.

Let�s look first at some catastrophic kinds of trials, and then later perhaps at some personal trials we all face.

Catastrophic Suffering

Some weeks ago a devastating tsunami took the lives of more than 160,000 of the Lord�s children. How does one understand an event such as that and even see the Lord�s hand in developing additional love and trust in Him as a result of that event?

Many do not understand God and His purposes, as reflected in the following observations by current writers:

1. �In the aftermath of a cataclysm, with pictures of parents sobbing over dead infants . . . , faith-shaking questions arise: Where was God? Why does a good and all-powerful deity permit such evil and grief to fall on so many thousands of innocents? What did these people do to deserve such suffering?� (William Safire, �Where Was God?� New York Times, 10 January 2005, A23).

2. Another one: �How do people of faith make sense of the senseless? The answer is, we can�t. The problem of suffering in this world has never been fully understood and cannot be completely explained� (Tom Schaefer from the Wichita [Kansas] Eagle, in �Why Did God Allow Tsunami Disaster?� Deseret News, 1 January 2005, E2).

3. One last one: A reverend said, �The disaster has shaken my faith.� A member of another Christian church said it had �made him �hate God.�. . . [He] now says that if God existed, this tragedy would have been prevented� (in Karen Mazurkewich and Geoffrey A. Fowler, �When Faith Is Tested,� Wall Street Journal, 7 January 2005, W1, W10).

Certainly none of us as Latter-day Saints should be unduly surprised by prophesied last-day events such as these. The Lord said:

And there shall be signs in the sun, and in the moon, and in the stars; and upon the earth distress of nations, with perplexity; the sea and the waves roaring. [Luke 21:25]

And the . . . waves of the sea heaving themselves beyond their bounds. [D&C 88:90]

I bear testimony that often, in the midst of suffering trials, afflictions, and discouragement, those very circumstances tutor us in developing increasing love and trust in God. Consequently, what a great blessing those trials are!

Individual Suffering

My purpose here today is not to focus so much on worldwide events but more so on individual suffering and trials, although the principles we discuss can apply to both.

If I could catalog suffering and trials among young people of your age, it probably would include some of the following entries:

� �I have prayed fervently for something, but it has never occurred. Why won�t God help me?�

� �Why did my father have to die and leave my mother and us alone?�

� �Why am I struggling with this chronic illness that makes me miserable most of the time?�

� �Why am I not worth anything? It seems that others feel that way about me, and I do too. I feel worthless.�

Brothers and sisters, is not that kind of suffering very real for many of us, and very intense as well? Here are some more:

� �I have prayed and fasted for an eternal companion, but no one has come.�

� �Why did he break up with me? Things were going so well. My heart is broken.�

� �We thought the purpose of marriage was to have children. We have prayed for years, and none have come.�

� �I failed another algebra test. Why am I so dumb?�

� �I am so discouraged. I�m not sure where my life is going. I feel surrounded in darkness, depressed, and have little or no hope.�

� �Where will the money come from for our apartment, our food, our books, our insurance, our car?�

� �Why am I so heavy? They say I�m bigboned, but the truth of it is, I�m just downright fat.�

Well, we could add a lot more suffering to that list, could we not? A struggling missionary asked me, �Elder Cook, when will this �happiest two years of my life� be over?�

A suffering friend once said, �I have been keeping the commandments and trying to do what is right. Why do they even call this plan �the plan of happiness�?�

Those are some very real questions. Unlike some in the world who do not understand the purposes of suffering, Latter-day Saints, thanks to the Restoration of the gospel, in large measure do understand. Why then do even the righteous suffer?

The Righteous Suffer but the Lord Delivers Them

Many are the afflictions of the righteous: but the Lord delivereth him out of them all. [Psalm 34:19]

�After Much Tribulation Come the Blessings�

Ye cannot behold with your natural eyes, for the present time, the design of your God concerning those things which shall come hereafter. . . .

For after much tribulation come the blessings. [D&C 58:3�4]

It is interesting to note that there would be even more suffering if it were not for the righteous in the land:

If it were not for the prayers of the righteous, who are now in the land, that ye would even now be visited with utter destruction. . . .

But it is by the prayers of the righteous that ye are spared. [Alma 10:22�23]

Will you, right now, those of you here listening to me, humble your heart and prayerfully consider these additional words I am going to quote from the Lord? Do it with the Spirit, and I am confident that they will humble your heart, strengthen your faith, and increase your love for Him, in spite of some of your current trials. Here are some of the Lord�s answers as to why He allows such suffering.

Suffering Is to Prove Oneself

Therefore, be not afraid of your enemies, . . . I will prove you in all things, whether you will abide in my covenant, . . . that you may be found worthy. [D&C 98:14]

Suffering Creates a Witness Against Sin

When the Saints were being cast into the fire in Alma�s day, he said:

And he [the Lord] doth suffer that they may do this thing . . . that . . . the blood of the innocent shall stand as a witness against them. [Alma 14:11]

Suffering Teaches Obedience

And my people must needs be chastened until they learn obedience, if it must needs be, by the things which they suffer. [D&C 105:6]

Suffering Teaches Patience and Faith

Nevertheless the Lord seeth fit to chasten his people; yea, he trieth their patience and their faith. [Mosiah 23:21]

Suffering Assists One to Repent and Be Forgiven

Verily, thus saith the Lord unto you whom I love, and whom I love I also chasten that their sins may be forgiven, for with the chastisement I prepare a way for their deliverance in all things out of temptation, and I have loved you. [D&C 95:1; emphasis added]

Isn�t it wonderful that the Lord�s motive in allowing suffering truly is love, and He will even prepare a way for our deliverance? Truly He has loved us during these serious trials, in spite of what some may think.

It is evident, brothers and sisters, that the Lord will use tragedy and sorrow to help humble His people and thereby cause them to repent and be saved. Listen carefully to this: He loves you more than your being perfectly happy day by day, and thus He will do what is required to purify you so you can return to Him.

Suffering Can Occur from the Lord Hedging Up Your Way

I will not succor my people in the day of their transgression; but I will hedge up their ways that they prosper not; and their doings shall be as a stumbling block before them. [Mosiah 7:29]

Suffering Brings Forth Righteousness

For whom the Lord loveth he chasteneth. . . .

Now no chastening for the present seemeth to be joyous, but grievous: nevertheless afterward it yieldeth the peaceable fruit of righteousness unto them. [Hebrews 12:6, 11]

Be Patient in Suffering

Be patient in afflictions, for thou shalt have many; but endure them, for, lo, I am with thee, even unto the end of thy days. [D&C 24:8]

The Lord did strengthen them that they could bear up their burdens with ease, and they did submit cheerfully and with patience to all the will of the Lord. [Mosiah 24:15]

Lightening Your Burdens Through Christ

That they should suffer no manner of afflictions, save it were swallowed up in the joy of Christ. [Alma 31:38]

And then may God grant unto you that your burdens may be light, through the joy of his Son. And even all this can ye do if ye will. [Alma 33:23]

Aren�t these profound answers clarifying why the righteous suffer? We, of all people, ought to stand and humbly bear testimony of how God�s great love can be found in the suffering of individuals, as well as of nations, and be able to explain to a large degree why much of that is occurring. Of course, no man knows all the purposes of God, and thus does not fully understand the full purpose of suffering. That is only known by the Lord.

On a personal note, I think in my own life of what a challenge my wife and I had when we were first married and went for nearly five years without having children, even though we fasted, prayed, and had numerous priesthood blessings concerning that challenge. We suffered much. However, in time, after adopting our first son, seven others came naturally, and we now stand as the parents of those eight children, plus 21 grandchildren.

Does the Lord fulfill His promises? He does. Be patient. Wait upon the Lord. He does love us.

Here is another personal example showing the uniqueness of the Lord�s gifts. All of my adult life I have suffered with very difficult health problems, some of which have been life-threatening. What lessons were taught in the process of all those years! I believe they could not have been learned any other way. They have helped me to be more Christlike. Truly the Lord knows the end from the beginning and will tutor, correct, mold, and even refine you in the furnace of affliction. He will do so until He has accomplished His purposes in purifying you, sanctifying you, and helping you draw closer to Him.

These kinds of gifts from the Lord are not always easy to understand, but I count them as priceless gifts to me and my family. One can sense the deep feelings of the Lord when He spoke these words:

For what doth it profit a man if a gift is bestowed upon him, and he receive not the gift? Behold, he rejoices not in that which is given unto him, neither rejoices in him who is the giver of the gift. [D&C 88:33]

I pray that the Lord will help us to recognize even these unique gifts of suffering and to always be found giving thanks for them to the Giver of the gifts.

The Lord Sews a Spiritual Tapestry into All Our Lives

How little does man understand the purposes of God! How true these words:

For my thoughts are not your thoughts, neither are your ways my ways, saith the Lord. [Isaiah 55:8]

Great is his wisdom, marvelous are his ways, and the extent of his doings none can find out. [D&C 76:2]

President Thomas S. Monson has spoken recently of �small hinges� upon which the very history of our lives turn (�Choose You This Day,� Ensign, November 2004, 67). A few weeks ago my family and I discussed that thought, and we were deeply humbled to see how the Lord had directed all of our lives.

One married son said, �Had I not been the best man in my older brother�s marriage, I would have missed meeting my future wife.�

His wife responded, �If 15 years earlier my family had not determined to move to Ecuador, where they met your family, they would not have been invited to the reception and thus perhaps I never would have met my husband-to-be.�

How does the Lord sew that kind of life tapestry to bring about such wonderful blessings?

Another son mentioned, �Dad, had you not happened to be assigned to a particular stake conference, you would not have met my future wife and facilitated our meeting one another.�

His wife said, �I just happened to go to that conference, where my father presided that day, instead of my own stake.�

And I must add, how was it that the president of the Quorum of the Twelve happened to assign me to that particular conference that weekend?

My wife and I commented on the fact that had we not felt inspired to move from Arizona to Utah 35 years ago, much of what has just been said would not have happened. We concluded that in many ways our children�s �small hinges� were dependent upon our �small hinges� as their parents.

Of course, as Latter-day Saints we know that all those events are not predestined, but it is the Lord�s loving hand in our lives attempting to bless us with the very best that we can receive.

Add to all of this the times the Lord has used daily experiences to mold your personality, to refine your attributes, to help you be more Christlike. How complex it appears to man. How difficult it would be to influence all within one man�s life in one day, let alone throughout his whole life. Think of the orchestration that is going on among your whole family, the whole community, and the whole world. Could any man ever comprehend the love and works of the Lord? I think not.

Brigham Young once said, �Every trial and experience you have passed through is necessary for your salvation� (JD 8:150). How blessed are we, my dear brothers and sisters, to recognize the Lord sewing this spiritual tapestry of our lives to produce a more Christlike individual. I remind you of these words:

Wherefore, brethren, seek not to counsel the Lord, but to take counsel from his hand. For behold, ye yourselves know that he counseleth in wisdom, and in justice, and in great mercy, over all his works. [Jacob 4:10]

Could any man think to counsel the Lord on anything, even having a small view of what has just been described? All of this causes me to feel deeply the need to always pray more fervently for the will of the Lord in my life and, whatever I ask, to be sure to condition it upon His holy, divine, all-knowing will.

How great is the wisdom of God! How great is His love! I stand humbled�in absolute awe of my Heavenly Father, His love for us, and His glorious plan of happiness.

The Lord Will Help Us with Our Suffering

Prayerfully listen to these words:

In all their afflictions he was afflicted. And the angel of his presence saved them; and in his love, and in his pity, he redeemed them, and bore them, and carried them all the days of old. [D&C 133:53]

No trial or suffering will separate us from the love of God, said Paul the Apostle:

Who shall separate us from the love of Christ? shall tribulation, or distress, or persecution, or famine, or nakedness, or peril, or sword? . . .

For I am persuaded, that neither death, nor life, nor angels, nor principalities, nor powers, nor things present, nor things to come,

Nor height, nor depth, nor any other creature, shall be able to separate us from the love of God, which is in Christ Jesus our Lord. [Romans 8:35, 38�39]

Men Can Bring Suffering upon Themselves

We have spoken of the suffering of the righteous�now a word regarding the suffering of the unrighteous. The Lord said:

But if they would not repent they must suffer even as I. [D&C 19:17]

Also, one could surely increase his suffering by not keeping the commandments of the Lord, couldn�t he? The Lord said:

Remember to sin no more, lest perils shall come upon you. [D&C 29:3]

And thus we see that except the Lord doth chasten his people with many afflictions, yea, except he doth visit them with death and with terror, and with famine and with all manner of pestilence, they will not remember him. [Helaman 12:3]

It ought to be easy to see in the case of those who sin that they bring much suffering and misery upon themselves by not keeping the commandments of the Lord. That is unfortunately true of some of us who know better but who are either not keeping the commandments or are just skirting the edges of some.

How many are suffering right now as a result of not keeping the Word of Wisdom�not only physically but spiritually being alienated from the Lord? How many other evil sins�such as robbery, abuse, or immorality�and thereby great suffering, result from someone not obeying the Word of Wisdom?

What great blessings are promised to those who obey the Sabbath day, even �the fulness of the earth� (D&C 59:16; see also verses 15 through 21). What great losses, spiritually and temporally, come our way if we disobey?

What about the suffering that comes from those who do not pay an honest tithe and offering and therefore struggle with debt and financial hardship all the days of their lives?

What about the suffering that results from dishonesty or involvement in risky financial endeavors�even loss of trust, divorce, and imprisonment?

What great chastisement comes to one who disobeys the law of chastity and is involved in immodesty, petting, pornography, and fornication. He loses his faith, loses the Spirit, and even could lose his membership in the kingdom of God.

What suffering comes to one who skips his Church meetings and avoids having a Church calling? He not only loses the opportunity to give needed service but also retards the growth and development of his own soul.

Incorporated in all of the laws of the Lord are blessings that will be yours when you keep them and consequences causing you to suffer when you do not. When we disobey the Lord, we truly learn that �wickedness never was happiness� (Alma 41:10).

A Few Suggestions on Cheerfully Suffering Tribulation in the Redeemer�s Name (D&C 138:13)

1. Keep the commandments of the Lord with exactness. By so doing you will avoid the suffering of the wicked and reap the blessings the Lord has promised to the obedient.

2. Endeavor to see more fully the Lord�s hand in your life and in the lives of those around you. The Lord loves you. Each day He adds to the beautiful spiritual tapestry being sewn of your life, if you allow Him to do so.

3. When faced with adversity, trial, or suffering, do your best to increase your faith in the face of the trial. Many of less faith, when faced with a serious trial, become angry, weaken their faith, and thereby struggle and suffer more. Perhaps the real test of your faith is how to increase your faith and your love when trials come your way.

4. Be patient. Wait on the Lord. Plead fervently for understanding and the ability to endure. Remember, we are not to counsel Him; He will counsel us. Be patient. Trust in Him for that which you do not know, and you will come to know much more. You will feel more profoundly of His personal love for you. Remember the words �even this will pass� and these sacred words: �The Lord gave, and the Lord hath taken away; blessed be the name of the Lord� (Job 1:21).

5. Do not be discouraged along the way. My young friends, the devil delights in discouraging people and causing them to feel inadequate, unworthy, unneeded, and unloved. Discouragement is a tool of the devil. He uses much of our suffering and misery to bring about discouragement and thus fulfill his purpose. May I say with a smile: Cheer up, pray, read in the scriptures, bear your testimony, sing, express love to God and to others, serve, obtain a priesthood blessing if need be, and do away with discouragement, the devil's influence upon you.

6. Humble yourself and repent of your personal sins. Humility before the Lord, a broken heart, and a contrite spirit truly seem to be the offering and sacrifice required of the Lord. The peace of the Spirit will then rest upon you and the love of God will fill your soul.

Final Testimony

Well, brothers and sisters, let us return to where we began: �Where is God in all of the suffering that is going on in the world?� I testify of my certainty of His loving involvement. He uses trying circumstances for His purposes to develop true disciples of Christ, even a Zion people.

I express gratitude for the Lord�s hand upon me through the years. He has answered all of my prayers�even though at times I had no idea what His purpose was, nor perhaps still do. He has blessed me with many wonderful days�more of those than of difficult days of suffering and despair. And yet even in those difficult days I have felt the Lord reach out to me, felt the darkness disperse, and felt His personal love fill my very soul.

I bear witness that He is a God of love. He does love His children in spite of what many in the world may think. I bear testimony that the grace of the Lord Jesus Christ is sufficient for all men.

May God bless us to be more humble, more repentant, more filled with faith, more trusting, and more loving to one another and to Him. This is His work. This is the true Church of Jesus Christ. The Church and the fullness of the gospel have been restored.

Living apostles and prophets of the Lord Jesus Christ walk the earth in our day. Of these things I humbly bear testimony, in the name of Jesus Christ, amen.

Tuesday, February 26, 2008

A Timeless Longing for Dignity and Freedom, Spoken Word by Lloyd D. Newell


Delivered By: Lloyd D, Newell

On the first day of December 1955, a prim, middle-aged woman riding a bus home from work made a decision that would shake the country. Rosa Parks, a black seamstress who was tired after a long day’s work, refused to give up her seat on the bus so a white man could sit down. As a result, she was arrested and jailed. This act of civil disobedience triggered a series of events considered now to be the beginning of the American civil rights movement.

Martin Luther King Jr. said of Rosa Parks’s resolve: “It was an individual expression of a timeless longing for human dignity and freedom. . . . She was anchored to that seat [on the bus] by the accumulated indignities of days gone and the boundless aspirations of generations yet unborn. She was a victim of both the forces of history and the forces of destiny.”1

Her resolute decision in behalf of dignity and freedom began to tear down the walls of bigotry. Years later, Rosa Parks would be awarded the two highest civilian awards in the United States: the Presidential Medal of Freedom and the Congressional Gold Medal. She would be called the mother of the modern-day civil rights movement.

Part of her success in advancing human rights was found in the quiet strength of her character. Rosa Parks refused to become bitter or vengeful when she was denied justice; instead she believed that “a heart filled with love could conquer anything,” even prejudice.2

And love is something all of us can have. It can motivate us to stand up for what’s right, as Rosa Parks did, and promote the common welfare of all peoples. It can inspire us to see past differences and treat all of God’s children with dignity and respect. As we do so, we’ll find that both people and the times can change for the better.
1 In Douglas Brinkley, Rosa Parks: A Life, (2000), 141.
2 Douglas Brinkely, Rosa Parks, 14.
Program #4094

Monday, February 25, 2008

Isn't That AMAZING

In this month's Ensign (either April or May 2006), there is a moving account of Ann Roquemore, whose father passed away while she was serving her mission. When she heard the news, her "sobs came in painful gasps," her seeking consolation in prayer resulted in a revelation of great power. She said:

After a day of confusing stupor, after a heart breaking conversation with my mother, amid all the agony I was suffering, the moment I spoke the words ‘Dear Heavenly Father,' peace enveloped me, my pounding heart stilled, my breathing calmed. In that instant, I knew that Father in Heaven loved me. On a lonely planet in a vast galaxy among countless other galaxies, a tiny, suffering voice was heard and solace was given."

This excerpt is from BYU-Hawaii Devotional given by
President Eric B. Shumway on May 4, 2006

Sunday, February 24, 2008

I Am in Good HANDS

I started to cough two weeks before the Chinese New Year break, and it didn't get well as expected with medical treatment. I woke up early this Monday morning to call the sister missionaries to contact elders in my ward for a priesthood blessing. Because one of the elders in my ward would be transferred to another area, the elders in Tao 3 ward gave me a sweet blessing. I'm grateful that they made time for me because it was their preparation day and they could have had set up an appointment some time after 6pm.

On Thursday afternoon, I asked my mom to ride me to the clinics to see the doctor with worsen symptoms. My doctor changed the prescription and put me on antibiotics and also asked me to receive a respiratory treatment to help me breath more easily. I went back for follow-up appointment two days later and discussed the possible situations I'm going through. While reflecting on all these things that happened, I thought I am in good hands, meaning the care from a good doctor. Yet, when I wondered if I should put that much trust in that doctor, I then realized that I've always been in good HANDS, meaning being cared by a loving Father in Heaven, who loves me very much and is aware of what I am going through. Therefore, all these things shall give me experiences and trust Him more with all my heart. I'm grateful to have such a knowledge that brings me peace and reassurance that everything will be all right.

肺炎, 好複雜Diagnosis for Pneumonia is such a complicated thing!!!

肺炎

主講:林口胸腔二科 王圳華  

記錄:林口內科部 黃嘉勳

1 Introduction

在臨床上,懷疑病人得到肺炎時;臨床醫師首先要問自己幾個問題:

第一個問題:病人的疾病是否因感染所造成(因為也可能是其它原因所造成)。

第二個問題:若病人的疾病是因感染所造成,那感染是屬於那一類。從呼吸系統來看,上呼吸道、氣管、肺、肋膜或者是其它部位均可因感染而致病,它是否真的屬於肺實質上的病變。

第三個問題是疾病的嚴重度;因為疾病的嚴重度影響到我們治療的方向,是否需要住院治療以及癒後的判斷。

第四個問題,那一個致病菌導致疾病的發生?還沒有一個很確定的培養結果以前,能根據以往的經驗來判斷出最有可能的致病菌。否則,等到培養結果出來,說不定病人已病重死亡了。

所以我們首先要有這樣的認知。再來就是確認病人的疾病,這是才能對疾病有進一步的了解。在整個確認、治療過程中,如果病人未能如預期中改善,要如何用什麼方法來做進一步的確認?

2 病史與理學檢查

一個感染的情況到底是怎樣,最重要的是病史(History),了解過去這段時間所發生的問題;第二個就是理學檢查,大家都很清楚。如果pneumonia是一個lobar pneumonia的話,它可能就會聽到local inspiratory crackle、這個地方可能敲到是一個dullness percussion;因為它可能會consolidation,所以在聽診上可以聽到bronchial sound。所謂的bronchial sound就是呼氣與吐氣時它的pitch是一樣的,所以呼、吸音是一樣的。正常的peripheral sound是alveolar sound;吸氣時alveolar打開所產生的一個磨擦的聲音;而吐氣時,正常是沒有聲音的。如果在吸氣、吐氣時,在peripheral都可聽到經過bronchial的聲音,那就是bronchial sound。這時,就要考慮以下幾個原因:一個是tumor所造成的obstruction,一個是consolidation,那另外像friction rub或pleural effusion等。

typical pneumonia裏,常見的臨床表徵有fever,濃痰或者是動脈血氧有變化等等。在做肺炎的鑑別診斷時,要看WBC有沒有leukocytosis; X光片是最重要的一個診斷工具。Pneumonia基本上一定要X光片上有infiltration,才能說它是typical pneumonia。一個病人因發燒或lung complaint住院,要知道他的infection出在那個地方。有些病人的臨床症狀像pneumonia而事實上它並不是pneumonia。譬如 病人有cough的症狀,要考慮幾個原因。它有可能是cancer或asthma所引起的。若X光片正常的話,要特別注意要做鑑別診斷。譬如病人有濃痰症 狀,它不見得單只由肺炎所產生,asthma或chronic bronchiectasis 也會產生很多的痰。此外,hemoptysis,pleural pain,wheezing也是肺炎常見的症狀。

Fever的話,尤其是 X光有非typical的infiltration的,一般在治療3 - 5天,他的fever或症狀就應該逐漸的改善。但若仍有fever時,就要考慮是否有autoimmune disorder,vasculitis,或者是其他unusual infection。所以病人有症狀時,不見得他就是pneumonia;在診斷治療病人整個想法不要focus在一個地方。要搜集更多的資料,包括理學 檢查,Lab,怎樣做culture,都要搜集更多的資料,才能做一個判斷。

3 肺炎的分類

在沒有很好血液、痰液、細菌培養結果以前,我們一般將pneumonia 分成以下這幾種:community-acquired,hospital-acquired (nosocomial)以及immunocompromised。在community-acquired中,最常見的是gram positive bacteria,像Streptococcus pneumoniae,這是最常見的;其他像Hemophilus influenza也常見;另外在較年輕成人中,Mycoplasma或Chlamydia也常見,而有些則屬於病毒感染。如果認為病人是一個 community-acquired pneumonia,在尚未有細菌培養結果之前,或者尚未證實致病菌前,我們要根據常見的致病菌,經驗上給予抗生素治療。在Nosocomial pneumonia的話,早期的nosocomial pneumonia,它的pathogen與community pneumonia是一樣的;後期的nosocomial pneumonia,它的pathogen則要考慮gram negative bacteria。像enterococcus,通常會使病人的臨床症狀更加嚴重。有些是Staphylococcus aureus,在醫院常見是ORSA。有些是屬於高抗藥性的菌種,如Acinetobacter,Pseudomonas,很多antibiotic對它 均無效。這些在治療上,尤其是時程上,都要加以考慮。Immunocompromised pneumonia的pathogen大都是伺機性的(opportunist)包括fungus,pneumocytto cavinii。Invasive test包括throat swab(目前做的比較少)sputum或tracheal的aspiration。如果病人雖經治療,但效果不佳的話,我們可能要做更invasive 的檢查,比如做bronchoscope進去把一些pathogen抽出來;甚至做open lung biopsy來做一個tissue的proof。這些invasive的檢查通常是在病人的整個症狀未能如預期改善的情況下來安排。

今天的課題將pneumonia分成三個部份來談,一個是community acquired pneumonia,一個是hospital acquired pneumonia,另外一個是immunocompromised pneumonia。首先要知道如何做鑑別診斷,診斷之後要如何處理,處理的過程有問題時,如何來想第二步;或者是下一步如何來做更正確更有效的治療。

3 Community Acquired Pneumonia

Community-acquired pneumonia在臨床上是相當常見的。它在美國的死亡率是所有疾病中排名第六位。一般門診病人,它的死亡率是相當罕見的。住院的病人若 combined其它的disease,那它的死亡率就會增高許多。大部份community acquired pneumonia它的culture都是negative的。比較資深的住院醫師在care病人時就會發現,大部份community- acquired pneumonia的病人,其blood或sputum culture都是negative的。所以empiric approach對community-pneumonia而言是相當重要的。一個門診懷疑pneumonia的病人要如何approach,除了首先要 有很好的鑑別診斷以外,更要了解在這種情形下,最可能的pathogen是什麼。第一線就要給他最有效的antibiotic,可以讓病人的症狀得到很好 的緩解。

在常見的bacteria中,Streptococcus pneumonia是佔第一位、Hemophilus influenza排第二位,但Staphy. auerus 較少見。另外常被人遺忘的Myoplasma,也非罕見。如果X光片沒有很明顯或典型的變化時,就得考慮viral infection。這些在臨床上要特別記在腦海中。在臨床上大部分typical pneumonia的症狀,譬如最常見Streptococcus pneumonia在臨床症狀上先有一個chills,再接著是high fever。如果有pleural involvement,就會有pleuritic chest pain。它的特徵就是吸氣時會胸痛,而吐氣時不會或是cough時會胸痛,它跟cough很久之後的胸痛是不同的(pleuritic chest pain是整片的,而prolong cough引起的痛是定點痛,在muscle insertion的位置)。有時病人因怕痛而不敢用力吸氣,tidal volume因而降低,而看起來有點喘。在理學檢查上可聽到friction rub (捻髮音)。肺炎在早期可能無痰,而後resolution時,可能會有purulent sputum,這是pneumonia臨床上典型的表現。這些症狀並不見得每個肺炎病人均有。若有,就要懷疑是否有pneumonia。另外病人有chest pain的比例較少,chills及rigors也較少見。通常臨床症狀以fever及productive cough為主。

在實驗室檢查方面,CBC/DC有leukocytosis並且有left shift。X光主要的是infiltration及air bronchogram。所謂的air bronchogram指的是在inflammation process,由於肺實質的浸潤。因此bronchial tree內的air就會很清楚。所以air bronchogram代表的意義是肺實質的疾病。如果它出現在一個lobe或一個segment,我們就要懷疑它是以pneumonia為主。除此之外,consolidation,或者是因gram-negative bacteria或者是TB infection、fungus infection。在X光片上可看到cavitation lesion,可幫忙我們來做鑑別診斷。

在血液細菌培養結果出來以前,sputum smear對於最初的治療病人是很有幫忙的。做sputum smear,首先要排除上皮細胞與口水的污染;一個好的sputum smear,指的是上皮細胞<10個,pmn>25個。一般來說,所謂的sputum smear 1+代表在HPF下neutrophil 1-9個;2+是10~29個;3+就是neutrophil>30個以上。Sputum smear的結果要neutrophil 2+或>25個以上,才是一個從low respiratory tract來的有效檢體,並且依據gram stain的結果是positve或negative,依最常見的致病菌來用藥。在實驗室檢查方面,還包括血液及痰液的細菌培養。

就一般的pneumonia而言,胸部X光的finding大部份都會compatible with symptoms。但是如果X光finding是negative時,要怎麼辦?臨床上病人有leukocytosis,cough with puruletn sputum症狀很像肺炎,但是X光卻是negative的;它是否一定就不是肺炎呢?有幾個可能性要考慮,第一個就是所謂的 "blossoms"病人剛住院時,可能有volume depletion 的現象,在開始治療後給予hydration;肺部的浸潤又跑出來。所以臨床上懷疑是pneumonia,但X光negative時,須要在治療後2,3天F/U X光。但是如果仍然是X光negative時,這時可考慮的CT exam。X光與CT兩者皆是影像學檢查;但是,有時X光上的對比較不顯著;些時可藉由調整CT number,在較低的CT number下即可將infiltration表現出來。在臨床上,也可藉由CT來做鑑別診斷。

面對一個pneumonia的患者,臨床醫師首先要區分他是一個typical或atypical pneumonia。以下幾個條件來區分。因為二者的pathogen及治療是完全不一樣的。就臨床症狀而言,typical pneumonia的cough與fever是伴隨存在的。Atypical pneumonia的fever是好好壞壞發作,通常不會chill,且以non-productive cough為主。X光的表現:typical pneumonia會有lobar或segmental infiltration;而atypical pneumonia X光的表現是interstitial infiltration。Typical pneumonia gram stain通常是positive,有顯著的leukocytosis,常見的致病菌為Streptococcus,H. influenza等。Atypical p[neumonia,gram stain通常是negative;leukocytosis是moderate。常見的致病菌還包含一些intracellular bacteria、如TB,Mycoplasma或者是viral infection。所以在治療pneumonia以前要先確定病人的症狀是typical或atypical。

對於一個community-acquired pneumonia,根據history,physical examination, laboratory及X光上的finding,來了解它疾病的嚴重度。對於一些較不嚴重的患者,可能只須一些empiric antibiotic,病人的症狀就會得到改善。對於中度的患者,可以給予empiric antibiotic,並且做sputum smear,culture,根據結果再來調整抗生素。對於病情較嚴重的患者,就須要較完整的檢查,包括blood culture,血清免疫檢查(例如 Legionella or Mycoplasma)。若有pleural effusion要做pleural effusion culture。在culture結果出來以前先給予empiric antibiotic treatment。在culture結果出來之後,根據pathogen給予正確的antibiotic治療。

對於一個60多歲 community acquired pneumonia的病人;如果病人並沒有comorbidity的情況(所謂的comorbidity指病人另有以下疾病如:阻塞性肺病?糖尿病?腎功 能不全?鬱血性心衰竭…慢性肝疾時),最常見的致病菌是Streptococcus pneumonia,第二位是Mycoplasma pneumonia,第三位是virus infection。所以,病人若無厲害的leukocytosis,臨床的症狀也不是很厲害時,只要給予口服抗生素即可,如macrolide。在台灣 地區有1/4~1/3的病人吃了erythromycin後會有腹部不適的症狀,可以改用第二代macrolide 如clarithromycin,或者給tetracycline治療,皆對streptococcus pneumonia有效。

但是病人若合併有其它器官的疾病(如心、肺、肝等),其可能的致病菌,第一個仍是Streptococcus pneumonia,其次是virus or H. influenzae,或是一個gram-negative bacilli。這些病人可能需要第二代的cephalosporin治療;特別是要能夠cover H. influenzae,因為它在community acquired pneumonia佔有相當高的比例。為什麼不給ampicillin?因為根據本院culture的結果,有50~60%的H. influenzae是對ampicillin有抗藥性的。在以前ATS的guideline裡,對於年紀較大的community acquired pneumonia門診病人會給第二代的cephalosporin;如果擔心他有Mycoplasma pneumonia infection的可能,要合併macrolide的治療;若不像Mycoplasma infection,則可不加。另外可加augmentin或其它(-lactam inhibitor agent。因為H. influenzae可能對第二代的 cephalosporin產生resistance。若病人懷疑有Legionella infection,一定要加macrolide antibiotic。

什麼時候決定讓病人住院?門診的病人,根據經驗給予抗生素治療後,但症狀仍未能改善,此時要讓病人住院。住院以後要觀察病人有沒有leukocytosis 的現象,若有,則表示他的疾病是較嚴重的。其它若病人有leukopenia,或者是WBC>20000以上,或病人的blood gas,creatine開始變差,出現hypoxemia,或者有conscious change,X光的浸潤比原先更厲害,有這些情況時,病人須要住院。若是病人來門診時已出現上述的症狀包括conscious change,有很厲害的chest pain(代表已involved pleural,表示發炎的範圍很大),heart rate變快,fever。有這些狀況就讓病人住院治療。在OPD,我們通常告訴病人,若吃了藥,但是fever或症狀在3天內並未改善,則須要到急診來 求診,代表其infection可能較厲害或用藥可能不對。有這樣的情況皆須住院來做進一步的評估。或者病人已有complication,都代表其症狀 加重,須住院處理。對於感染症,最重要的是找出致病菌。在門診肺炎患者最常見的致病菌是Streptococcus;而住院病人中, Streptococcus也是最常見的。另外要考慮Mycoplasma或H. influenzae的感染。

對於一個需要住院的community acquired pneumonia,其最常見的pathogen還是Streptococcus pneumoniae,H. influenzae;其它如gram negative bacillus,Legionella都要列入考慮。因其臨床較為嚴重,須要IV form的抗生素治療。在Guideline告訴我們,Aqueous- PCN大概會對Streptococcus有效。但是致病菌H. influenzae還是很多。剛開始治療時,最好還是給第二代的cephalosporin。根據過去的研究發現可以縮短病人住院的時間,使病人的症狀 很快的得到改善。若是擔心病人有Mycoplasma的感染,則須要加erythromycin或clarithromycin。所以對一個需要住院的肺 炎患者,若只給Aqueous -PCN或者Aqueous -PCN+gentamicin,大概是沒效的。Gentamicin在治療肺炎方面不具重要性。因為它在lung的濃度相當低,所以根據以往的經驗,給 予gentamicin治療大部份是無效的,而且容易造成一些腎毒害。所以目前對須住院的community-acquired pneumonia,首先還是先給第二代的cephalosporin;另外考慮是否給予macrolide。

對於severe form的community-acquired pneumonia,如果一開始有以下的狀況(如old age,comorbid illness,alcoholism,呼吸>30/min,BP down....)就須住院治療。住院之後若情況變差了,如leukopenia,leukocytosis,hypoxia,要知道如何調整藥物,並且根據培養的結果來調整antibiotic。Severe form的community acquired pneumonia常見的pathogen是Streptococcus,第二個是Legionella,另外是gram-negative bacilli。當一個病人住院以後治療結果不佳時,即要考慮這些pathogen。特別是Legionella pneumonia常會被忽略掉;尤其是年紀較大的病人。若病人入院後,他的感染相當嚴重,病人有ileus,病人無法進食或他無法對erythromycin tolerance,可直接用IV form的rrfampicine,因為rifampicine 可以cover Legionella的感染。若仍然無效時,可能要考慮病人有無Pseudomonas infection的可能。所以要用到第三代的cephalosporin或是其他的antibiotic可以cover Pseudomonas,包括ciprofloxacin,imipenem等或其它的antipseudomonas agent。在處理嚴重的community-acquired pneumonia時,一定要把Legionella及Pseudomonas列入鑑別診斷。用藥方面,在tissue或culture尚未證實以前,要先給予一些empiric antibiotic。Antiobic治療的時間,一般bacterial infection (Streptococcus)大概7~10天是足夠了。Mycoplasma大概要用10~14天。Legionalla infection對於immunocompetent的病人要治療14天;對於immunocompromised的病人要用到3個星期,這樣的治療才會adequate。原則上在評估此類病人病情後,給予adequate treatment,是根據ATS guideline,住院後給予IV form antibiotic;大約三天後follow up X光及CBD/DC;若已有改善,便可改成oral antibiotic。再觀察一天,即可讓病人出院。如果症狀仍未改善,則可能要考慮其他的pathogen。因為大部份Streptococcus pneumoniae的感染大都經2~4天的治療後即可改善。若未改善,即要考慮其他pathogen,是否有未想到的其他致病菌,譬如Legionella infection或是gram-negative bacteria等。

臨床症狀如crackle 可能先改善,但是X光大約需要7天才會出現改善的表現。若是Streptococcus pneumoniae有的要四個禮拜才會完全改善;有的文獻記載甚至要二個月才會痊癒。所以在X光上,只要infiltration有改善,就算臨床的治 療有改善。當病人對於所接受的治療沒有很好的反應時,要做以下的考慮。是否是抗藥性的菌種,是否是virus infection,或根本就是TB,fungus或PCP的感染,或是非感染性的病因如vasculitis,或是因tumor所造成的 obstruction。若病人的症狀仍未能改善,通常會安排bronchoscope的檢查,直接做tissue的proof或直接洗BAL。把裡面的 tissue或lavage fluid送去做culture,看看是否有罕見的pathogen。另外要做chest CT,可能X光看到的根本就不是pneumonia;或者它是由Sta. aureus infection所引起的pulmonary embolism,是multiple lung nodules或cavitation。有些則屬於pulmonary infarction。這些皆需要做鑑別診斷,或者懷疑是legionella infection要做serological test。若真正的情況還未改善,可能還是須要做open lung biopsy來做鑑別診斷。

4 Hospital Acquired Pneumonia

以下要介紹的是hospital-acquired pneumonia,其定義就是在住院48小時後產生pneumonia,首先要先排除incubation造成的pneumonia,它是在 hospital中所發生的。因hospital中的致病菌與社區型是完全不同的,所以在其治療與使用抗生素也是不同。一般發生的比例在千分之5~10。 使用呼吸器的病人有更高的比例。通常住院愈久,其產生hospital-acquired pneumonia的機會就更高。

造成的原因很多是因microaspiration 所形成,是在larynx地方產生一些colonization,aspiration進去,很多病人都是因為病情較嚴重,或是口腔衛生較差,所受到照顧 較差時,病人因disease較嚴重,會產生這些aspiration。疾病愈嚴重,發生的比例也愈高。此外有些病人可能會有胃酸逆流,GERD (gastroesophageal reflux disease) 或vomiting時所造成。另外,在呼吸治療人員或其他給予病人的inhalation therapy可能含有infectious factors。因contamination而造成感染,有些則是IV route,包括CVP catheter都會產生。所以一個hospital-acquired pneumonia一定要先了解其infection是否由口腔而來;若是的話,就要加強口腔衛生。同時亦須區分是否從catheter來的,或是從 inhalation來的。我們要先了解它是由何處所造成的感染。此外、病人會合併一些risk factor,可能是有severe illness,coma或是有COPD,CNS dysfunction。這些病人容易產生hospital acquired-pneumonia。

另外一個原因是醫護人員所造成的。在病房與加護病房皆常見。可能在摸完一個病人之後未洗手,就去接觸另一床病人。所以可能這一床ORSA,下一床也可能很快ORSA感染。所以在care病人時要記得洗手。另外一個是GI tract,有些病人胃消化不好或ileus以後,在腸胃道有很多gram negative的bacteria,很容易造成hospital-acquired pneumonia。此外,用藥也會造成病人產生厲害的hospital-acquired pneumonia,包括sedation agent及steroid surgery過久或病人on endotracheal tube。

有個問題是on endotracheal tube之後是否還會產生microaspiration?答案是肯定的。因endotracheal tube內有一個cuff,病人呼吸或動的時候,cuff還是會動。所以一些oral flora反而更容colonized到cuff上。所以on endotracheal tube的病人產生hospital-acquired pneumonia的機會更大。此外,包括upper airway沒有辦法很有效的protection,反而更容aspiration進來一些oral cavity colonization的bacteria。

其它,如Antacid agent,有些病人我們怕他會產生stress ulcer給他H2-blocker之後,反而使胃內一些有用的細菌不見了,一些致病菌反而增生,造成病人在aspiration時更容易造成hospital-acquired pneumonia。另外就是NG feeding,很多病人本身胃消化不好,會造成micro-aspiration。所以在臨床上,如果病人用NG feeding,病人尚有mild fever;用antibiotic卻都沒有效時;在胸腔二科的經驗,即是給予NPO。這一類的病人fever大概都在38.5oC左右;做過很多細菌培養,結果都是negative。Sputum culture大部份是mixed flora。如果一直持續在fever。這時就要考慮他可能是從NG feeding所造成的microaspiration。可以把NG tube拔掉,NPO 3天看看。過去我們曾經做過研究,如果病人mild fever的話,我們給它用pH meter來測定食道;發現在NG feeding,continuing feeding時,病人GERD的情況反而更明顯。而Bolus feeding時,在大量灌食30分鐘後,病人胃酸逆流會更明顯。有時胃酸逆流會involved到upper esophagus。代表NG feeding本身會使cardiac sphincter dysfunction。所以胃的很多東西會逆流上來,容易因為這樣產生一些microaspiration造成pneumonia。

一個hospital-acquired pneumonia,我們要如何去evaluation。當一個hospital-acquired pneumonia進來時,要先了解history,照X光,blood gas,CBC/DC看他是否是典型的pneumonia。要做culture,能取得的tissue都要做culture。病人有pleural effusion的話,要做tapping,以取得culture上的證實。要做這樣一系列的檢查了解其pathogen從何而來。如果病人有combined其他comorbidity如COPD,CHF,DM等risk factors,這些病人算是較嚴重的,此時再考慮用antibiotic及pathogen時要特別注意。若病人具有以上risk factor,或最近有abdominal surgery則要考慮可能會有anaerobic pathogen,所以要給予clindamycin或(-lactamase inhibitor類的抗生素。

若病人是coma,有head injury,或者是diabetes,renal failure的話,他可能是ORSA或staphylococcus的感染,那就要給予vancomycin或是能cover ORSA感染的antibiotic。

若病人長期使用steroid,包括oral或IV form。可能要懷疑是Legionella infection,要用erythromycin或rifampin來治療。若病人胃口不好,rifampin和erythromycin都有IV form;可考慮用IV form治療。

如果病人是一個prolonged的hospitalization,或是ICU住很久,或是steroid用很久,有obstructive lung disease,就要懷疑是Pseudomonas,這時就要當做是較嚴重的pneumonia來治療。如果病人只是單純的hospital-acquired pneumonia,沒有其他的risk factors。常見的可能是gram-negative的enteric bacteria像一些enterobacter,E. coli,K.P,proteus,這些是沒有risk factor的hospital acquired pneumonia常見的病菌,所以用藥就要用到cephalosporin;因為Aq-PCN或是第一代的cephalosporin大概沒有效,或者是用一些(-lactamase inhibitor像Augmentin。

如果對penicillin過敏或是病情較厲害時,可用ciprofloxacin。或是病人有renal failure的話,要用atrezem來治療他的gram-negative bacillus的infection。

如果病人的病情較重,包括A: 呼吸速率變快,hypoxemia,urine量減少,或是有delivum / conscious change;或者B: 使用呼吸器,休克,使用昇壓劑。若有A群2項或B群任一項,皆表示病人是一個嚴重的hospital-acquired pneumonia。接下來要看他是否合併有其他的risk factors。如果沒有的話,若是住院5天以內發生的,那就是一般比較單純的hospital-acquired pneumonia考慮的pathogen是enteric gram-negative bacilli。用第二代的cephalosporin或是用(-lactamase inhibitor就會有效。

若是住院超過5天,那要 考慮他有沒有Pseudomanas或是Acinetobacter,這些都是較毒的細菌,一定要考慮到anti-pseudomonas的drug,包 括要給他ciproxin或是aminoglycoside。或者是加上一個anti-pseudomonas的penicillin類drug,如 Ticarcillin,或是用(-lactamase的inhibitor或是用Fortum,imipenem或atreozam。在排除病人有 immunosuppression的情況後,對於嚴重的hospital-acquired pneumonia,要懷疑是Pseudomonas,Acinetobactor,ORSA所造成的感染。

若是combined comorbidity,不管他住院幾天,要把它當成severe form hospital acquired pneumonia,一定要考慮Pseudomonas,Acinetobacter或是ORSA infection。在治療上要將這三種pathogen列入考慮。

對於hospital-acquired pneumonia在治療2-3天後,臨床上看病人的fever,leukocytosis有沒有改善?Culture結果如何。如果沒有結果,可能要再 做culture,通常在治療2-3天以後,給他follow一張X光,看他有沒有改善。如果臨床症狀改善了,他可能屬於non- pseudomonas,non-acinetobacter,non-ORSA的severe hospital-acquired pneumonia。

大部份只要monotherapy 14-21天就足夠了。如果臨床有改善,但致病菌是Peudomonas,Acinetobacter或ORSA,就要用ciprofloxacin,再 加上anti-pseudomonas的antibiotic,須要治療14-21天,這樣才能有效且足夠治療。

如果臨床上沒有改善;要更進一步evaluation。再重新看看病人是否有其他部位的infection沒有考慮到,包括是否有pleural effusion,或是可以考慮做chest CT;確定他是否有其他非infection的問題。有的要懷疑是sinusitis;或有沒有pulmonary embolism。如果還是都沒有效,還是要做open lung biopsy,來做tissue proof。以上是一個簡單的hospital-acquired pneumonia在臨床上的判斷和治療的流程。在hospital-acquired pneumonia最常見的還是microaspiration。所以在care病人時要注意幾個情況,包括將臥床病人搖高45度。文獻上指出這樣可減少病人的aspiration。另外就是on endotracheal tube;epiglotic suction要特別小心,避免aspiration;且儘可能不要emergent on endotracheal tube。因不僅容易產生trauma,也容易從inturbation裡造成infection。另外要減少oropharynx的bacterial load。還要減少contamination的感染,所以在和病人接觸後要洗手,以減少一些person to person的contamination。

5 Immunocompromised pneumonia

下要介紹immunocompromised 所引起的pneumonia。較常見的病因通常和immunity低落有關。包括cancer的病人,做過chemotherapy,或者是做過 transplantation的病人,或者是HIV的病人。這些都是屬於immunocompromised,其pathogen除一般常見的 bacteria之外,一些較罕見或是伺機性感染菌比例增加;像fungus,virus,PCP或是TB的比例都增加。所以對一個 immunocompromised host的病人的pneumonia,須要把這些pathogen列入考慮的範圍。

基本上要了解,因為這一類病人immunity較差,Immune system無法很快的反應infection的情況。通常會delay反應,對於這樣的病人,他的任何一個infection的signs都不能掉以輕心。所以病人只要X光片有不正常;或有headache、chill、chest pain;或者是病人on IV的地方出現了紅腫熱痛;或者是X光有一些不正常的新生或者infiltration,都要考慮到病人可能有infection。

X光常見的表徵常見的是consolidation,有一些是peribronchial的infiltration還有nodular lesion,其它包括cavitation。在consolidation裡,可能會有air bronchogram,peripheral location。例:一個做過bone marrow transplantation的患者,有fever,chills及leukopenia的現象,X光在lingual lobe有infiltration,consolidation,culture長的是norcardia。所以對於immunocompromised的病人,X光出現新的infiltration要懷疑是infection。

對於immunity intact的病人,pneumonia是屬於lobar或segmental為主,除非是virus infection。對於immunocompromised的病人,他的X光片上的finding就比較特殊,可能表現出來是bilateral interstitial的infiltration。除此之外,PCP也有類似的表現。Nodular pattern這一類的致病菌很多,如PCP fungus的infection會出現nodular pattern;有些則以開洞為主。所以在immunocompromised的patient,X光在peripheral nodule的地方有nodule in nodule or in cavitation。若無法證明,可以做chest CT來證實這樣的變化。因immunocompromised的病人,fever臨床表現會delay,所以X光有異常要積極的治療。

X光有consolidation,acute (<24>24 hours)要懷疑是fungus,norcadia,TB,PCP或者是drug induced。若是有peribronchovascular lesion,在acute phase要懷疑bacteria,virus或pulmonary edema。若有nodular infiltration in acute stage,常見的有bacteria;若有nodular infiltration in subacute stage時,fungus,norcardia是常見的。

對於一個immunocompromised pneumonia的治療流程,首先要考慮它是否屬於bacteria infection,若是,時間在24小時內,根據臨床上最常見的pathogen,做culture 給予empiric的治療。如果不屬於前者,懷疑是fungus infection要做bronchoscope或BAL來取得tissue proof。來排除一些如fungus,PCP的感染。

bone marrow transplantation的病人產生pneumonia時為例:early的pneumonia要懷疑是nosocomial infection。在late stage要懷疑fungus infection。Transplantation 100天以後,要懷疑是virus infection,以CMV最常見。PCP或aspigillos皆有可能。一個immunocompromised的患者,要注意其最可能的pathogen是什麼。

Aspergillus所造成的感染,在fungus infection是屬於較難治療者。它分成幾種:第一種ABPA (allergic bronchopulmonary aspergillosis),病人有asthma的症狀,IgE會高,要給steroid,臨床症狀會改善。另外一種是involved到vascular (angioinvasive),病人通常會大量咳血。臨床上有症狀時要積極治療。第三種是lung有aspergilloma,若沒有症狀就不須治療。因為對於aspergillus infection最重要的是invasive aspergillus,通常會在血管內增生,造成很厲害的fungus infection。診斷上,有時要做biopsy來證實。對於一個invasive aspergillus infection,目前以amphotericin B為主。臨床上懷疑是invasive aspergillus infection,就要給予amphotericin B的治療。

Pneumocystis carinii的感染:在ARDS或產生於immunocompromised host的一個opportunistic infection。在微生物學上有三個分期:cysts,sporozoites,trophozoites。

AIDS感染PCP通常於T-cell數目有關。PCP是屬於intracellular的pathogen。CD4 count <200以下,病人得pcp>

Source: http://www.cgmh.com.tw/intr/intr2/c3100/update/3-4/pneumonia.htm

Friday, February 22, 2008

Something Interesting About English...

我是一直到今天看中文的新聞然後google一下才知道原來有這麼回事...

I am not aware of it till I read the news in Chinese and later found out from Google.

Obama = Osama?

Or rather, does it equal Saddam? You see, Senator Barack Obama's middle name is Hussein. Obama is a member of the United Church of Christ but has a distinctly Muslim (Arab actually) sounding middle name, perhaps in honor of his Muslim paternal grandfather. Now that Obama is a rising star in the Democratic Party and is widely believed to be giving serious thoughts to a presidential run in 2008, an interesting drama is developing around his name.

Fingers are wagging in the political name calling. Republicans claim that the Dems started it all by calling the now defeated Senator Allen from Virginia by his full name, George "Felix" Allen and by slyly bringing up his Jewish heritage. I agree that Democrats are no babes in the woods when it comes to shrewd demagoguery. But that the Republicans are going to make much bigger political hay out of Obama's name is an easy bet. After all, this is the party that has perfected race and religion baiting. The Willy Horton campaign ads used by Bush's dad George H.W. Bush in 1988, racially charged ads against Rep. Harold Ford of Tennessee as recently as the 2006 mid term elections or Rush Limbaugh never forgetting to call Bob Dylan by his birth name of Robert Zimmerman, come to mind. Even a French ancestry is enough to cast a pall of suspicion on a candidate in Republican circles. During the 1988 Republican primaries Bush Sr. (again!), pointedly addressed his opponent (Pierre du Pont) by his given name of Pierre instead of Pete, the name Mr. Du Pont preferred to go by.

Source: http://accidentalblogger.typepad.com/accidental_blogger/2006/12/obama_osama.html

美2008大選歐巴馬、賓拉登差一字 NBC耍烏龍搞錯

更新日期:2008/02/21 18:02 記者許瑜菁編譯

美國國家廣播公司(NBC)最近鬧了個大烏龍,他們在播放歐巴馬的新聞時,竟然放了蓋達恐怖組織領導人賓拉登的照片,引發歐巴馬陣營的關切,隨後主持人趕緊向歐巴馬和觀眾道歉,聲明是無心之過。

NBC新聞主播:「俄亥俄州初選,還有再來...歐巴馬說什麼呢?」明明是提到歐巴馬,怎麼畫面上出現了恐怖大頭目賓拉登呢?NBC的新聞談話節目18日晚上播出時鬧出了大笑話,歐巴馬陣營立刻要求解釋,NBC也在幾分鐘之後立即道歉。

NBC解釋,這是一名圖片編輯所犯下的無心之過,絕對不是刻意修理歐巴馬,而這個事情的癥結可能就在於歐巴馬的名字,和賓拉登的名字歐薩馬只有一字之差。

把兩人搞混的烏龍事件這並不是頭一遭,去年CNN在討論賓拉登的下落時,字幕上竟然大剌剌地寫著「歐巴馬身在何方」!

說實話,真正和歐巴馬同名的並不是賓拉登,而是另外一個被布希形容成一代暴君的海珊。歐巴馬原名巴拉克‧海珊‧歐巴馬,中間名和伊拉克前總統海珊一模一樣。

CNN記者:你知道他中間名嗎?就叫作海珊。美國民眾:拜託讓我死了吧!

歐巴馬最近在美國初選中勢如破竹,接連拿下10州的勝利,不過要是他一旦成為美國總統,可千萬不要把他的名字念錯成歐薩馬,或是只念他的中間名海珊,這可是會引發大誤會的。

Source: http://tw.news.yahoo.com/article/url/d/a/080221/17/tw5o.html

Thursday, February 21, 2008

Deanne Bray--Another Person I Admire Personally


I saw Deanne Bray for the first time as an actress appearing on CSI then I recognized her immediately when I watched the show, Sue Thomas: F.B.Eye which she portrayed the main character of the show, Sue Thomas.

"Sue Thomas: F.B.Eye" follows the adventures of Sue Thomas at the FBI in Washington, D.C. Portrayed by Bray as one hard-headed, soft-hearted woman whose talent for reading lips with the help of her hearing-ear dog Levi, crack crimes and capture the bad guys. This remarkable, edge-of-your-seat drama is an inspiring tribute to the ability of the human spirit to overcome adversity and achieve great things.

Each week, "Sue Thomas: F.B.Eye" takes a dramatic inside look into high-profile FBI cases based on actual recent and current events. In season two, viewers can expect to see drug scandals, kidnapping plots, abuses of power and terrorist activity as well as explore the differences between the deaf and hearing worlds.


Deanne was born with a severe hearing loss that might have been caused by German measles. She is deaf in her right ear, and uses a hearing aid in her left ear, which has some hearing. That, plus reading lips, helps her communicate. She also uses American Sign Language. You'll find out more about this amazing woman from her website.
http://www.deannebray.com/web/index.php

Sue Thomas in Real Life http://www.suethomas.info/

Tuesday, February 19, 2008

Finding Joy-- Spoken Word by Lloyd D. Newell 02172008


Delivered By: Lloyd D. Newell

One of the most popular courses taught at Harvard University is a class called “Positive Psychology.” In essence, the professor teaches how to find joy in living. One semester more than 800 students enrolled.1 What does it say about our society that we must teach “finding joy” at the highest levels of academia?

Many myths and misconceptions swirl about how and where to find joy. For so many, it is elusive. Some think that joy comes from money or material possessions, so they conclude that adding more of them will surely bring increased joy. Or we may think we can only have joy if our relationships are always stable and our careers are always successful.

But real joy does not depend on our social status or our bank account, and it can even be found in times of turmoil and disappointment. Joy springs from our attitude and outlook. It comes from simple gestures, like making time for family members or friends, clearing up a misunderstanding, expressing gratitude for the efforts of others, celebrating their successes, or taking time to listen to their worries.

This kind of joy is available not only during times of peace, when all is going well, but also when we face challenges, heartache, or pain. In fact, that’s when joy does its greatest service—it brings balance and peace to the harshness and stresses of everyday living. It lifts our sights and settles our souls.

Ask yourself where you find joy, and then diligently look for it there. If, at the end of the day, we remember and prize each moment of real joy, we will learn for ourselves the truth of what the Psalmist promised: “Weeping may endure for a night, but joy cometh in the morning.”2
1 See Leon Neyfakh, “The Science of Smiling,” The Harvard Crimson, Feb. 16, 2006.
2 Psalm 30:5.

Gems for Young Single Adults--Accentuate the Positive

"I come to you tonight with a plea that we stop seeking out the storms and enjoy more fully the sunlight. I am suggesting that as we go through life we try to 'accentuate the positive.' I am asking that we look a little deeper for the good, that we still our voices of insult and sarcasm, that we more generously compliment virtue and effort. Now I am not asking that all criticism be silenced. Growth comes of correction. Strength comes of repentance. Wise is the man or woman who can acknowledge mistakes pointed out by others and change his or her course.

"What I am suggesting is that you turn from the negativism that so permeates our modern society and look for the remarkable good among those with whom you associate, that we speak of one another's virtues more than we speak of one another's faults, that optimism replace pessimism, that our faith exceed our fears. When I was a young man and was prone to speak critically, my wise father would say: 'Cynics do not contribute. Skeptics do not create. Doubters do not achieve.' "

Topics: growth, optimism, faith

(Gordon B. Hinckley, "Be Not Afraid, Only Believe,"
CES Fireside for Young Adults, Sept. 9, 2001)

Copyright 2008 by Intellectual Reserve, Inc. Rights and Use Information:
http://www.lds.org/rights

We just came back from a walk






Both Becky and I are very happy now. Look at the pictures to see how happy and satisfied we both are!!!

好、更好、最好 Good, Better, Best

好、更好、最好

達林‧鄔克司長老
十二使徒定額組

我們需要放棄一些好的事情,來作其他更好或最好的選擇,如此便能培養出對主耶穌基督的信心,並且鞏固我們的家庭。

達林‧鄔克司長老我們大多數人都被要求去做多過於自己所能做的事。身為負擔家計者、父母、教會員工及教友,我們在運用個人時間和資源上都面臨著許多抉擇。

一、

我們應該先體認一項事實,即:光是好並不足以作為我們去做某件事的理由。我們可以做的好事太多了,根本沒有時間一一完成。有些事比好還要好,這才是我們生活中應當優先關注的。

耶 穌在馬大家中教導了這項原則。馬大「伺候的事多」(路加福音10:40),她的妹妹馬利亞卻「在耶穌腳前坐著聽祂的道」(第39節)。當馬大抱怨妹妹不管 事,讓她一個人伺候時,耶穌雖嘉許馬大的辛勞(第41節),卻教導她說:「但是不可少的只有一件;馬利亞已經選擇那上好的福分,是不能奪去的」(第42 節)。馬大「為許多的事思慮煩擾」(第41節)固然值得敬佩,然而向偉大的夫子學習福音卻是「不可少的一件」。經文中還有其他的章節,也教導人們某些事情 比其他事情更為有福(見使徒行傳20:35;阿爾瑪書32:14-15)。

我小時候的一個經驗讓我了解到,有些選擇固然很好,不過其他的選擇更好。我在農場住了兩年,我們很少進城。聖誕節禮物都是透過郵購型錄來訂購。我花很多時間仔細翻閱型錄。對當年的鄉下家庭而言,郵購型錄就像現在的購物廣場,或是網際網路。

型錄裡展示的某些商品在我心中留下深刻的印象。那些商品分為好、更好、最好三種品質。例如,有些男鞋標示好(1.84美金),有些標示更好(2.98美金),有些則標示最好(3.45美金)。1

我們在考慮不同抉擇的時候,要記住光是好是不夠的。還有其他更好的選擇,甚至最好的選擇。縱使某項特別的選擇要付出較高的代價,但是因為它的價值高出許多,因此也是最好的選擇。

想 想看,我們在看電視、玩電視遊戲、瀏覽網路,或閱讀書報雜誌上,如何運用我們的時間來選擇呢。當然,觀賞有益身心的娛樂表演或取得有趣的資訊很好,但那類 事情並不是件件都值得我們付出一部分的生命時間去獲取。有些事則更好,還有些事是最好的。主告訴我們要追求學識時,祂說:「要從最好的書中尋求智慧的言 語」(教約88:118)。

二、

我們有些最重要的選擇,是與家庭活動息息相關的。許多負擔家計的人會擔心由於工作的緣故,使他們沒有太多的時間陪家人。要解決這些優先順序上的衝突,實在並不容易。但是在我所認識的人當中,從來沒有人在回顧工作生涯時會說:「我花在工作上的時間還不夠。」

在 選擇如何共度家庭時光時,要小心不要把空閒的時間都耗費在只是好的事物上,而沒有把時間留給更好或是最好的事物。有位朋友在孩子還小的時候,好幾次在暑假 帶他們出去旅遊,包括參觀令人難忘的歷史古蹟。暑假結束時,他問十幾歲的兒子最喜歡哪一項暑假活動。孩子的回答讓這位父親學到許多事情,而聽他講起這件事 的人也是如此。他兒子說:「這個暑假我最喜歡的事,就是那天晚上你跟我一起躺在草坪上看星星、聊天。」對孩子而言,大型的家庭活動固然很好,但永遠都比不 上與慈愛的父親或母親一對一的相處時間。

孩子和父母也需要小心控管投注在私人課程、團隊運動、學校活動與社團等一些 優質活動的時間。否則孩子的活動若安排過多,父母就會身心俱疲,感到氣餒。父母應該採取行動,空出時間來進行家庭祈禱、家庭經文研讀、家人家庭晚會、家人 共聚的寶貴時光及個別一對一的時間,使家人能凝聚在一起,確立孩子對永恆價值事物的看法。父母應該透過跟孩子一起做事,來教導福音的優先順序。

家 庭專家提出告誡,不要造成「孩子的行程排得太滿」的情形。最近這個世代的孩子比以前更忙碌,家人相處的時間減少很多。針對這股令人不安的潮流所做的許多評 估中,有報導指出,花在有組織的正式運動的時間加倍了,但孩子每星期的閒暇時間減少了12小時左右,花在個人自由的戶外活動時間則減少了百分之50。2

表示有「全家經常共進晚餐」的人,其數目降低了百分之33。這一點最讓人擔心,因為全家人共度時光「在家裡一起用餐,是影響小孩的學業成就及心理調適的最重要指標。」3家人共同進餐的時間,也顯示出是防止孩子抽煙、酗酒或吸毒的最佳憑障。4這項給父母的忠告其中蘊含了重要的智慧:就是孩子最想要的是與父母共進晚餐。

戈登‧興格萊會長籲請我們要「努力盡到為人父母的責任,彷彿生活中的一切都有賴於我們是否善盡自己作父母的職責,因為事實上生活中的一切確實有賴於此。」他繼續說道:

「我要特別請弟兄們停下來仔細省思,自己在身為丈夫、父親和一家之主方面做得如何。要祈求指引,祈求幫助,祈求引導,然後在這項最重大的職責上聽從聖靈的低語,因為各位在家庭的領導會造成永恆持久的結果。」5

總 會會長團呼籲父母要「盡全力以福音原則來教導及扶養自己的子女。……家庭是過正義生活的基石,沒有任何方式能取代……神所賦予的責任。」總會會長團宣佈 說:「其他需求或活動,無論有多值得或多合適,也絕不可被允許來取代此項神所賦予的職責,而這職責唯有父母和家庭才能充分履行」。6

三、

教會領袖應知道,如果支會或支聯會一直要求教友在教會眾多計畫中,去做到每一件好的和可以做的事情時,教會聚會及活動就會變得太複雜,讓人疲於奔命。在這些事情上排定優先順序是必要的。

十 二使徒定額組成員一再強調,在教會計畫和活動中運用靈感判斷是非常重要的。多馬‧貝利長老在2003年的第一次全球領導人訓練會議中,教導了我們這項原 則。而李察‧司考德長老也在2004年對教會的同一批領袖提出忠告說:「調整你們的活動,使之切合你們當地的情況與資源。……務必滿足必要的需求,但不要 太過熱衷於進行許多美好的事。……記住,不要增加工作,卻要予以簡化。」7

羅 素‧培勒長老在去年的總會教友大會上提出告誡,當我們將過多的時間花在無謂且不太具有靈性價值的事上時,家庭關係就會惡化。他慎重告誡我們不要把教會的服 務變得太複雜,不要「讓無謂的事情佔據太多的時間、花費太多的金錢,消耗太多的精力。……要我們光大召喚,並不是要我們去裝飾我們的召喚,讓它變得更複 雜。創新不一定是要擴充,很多時候反而是要縮減……我們在教會中最重要的責任」,他說:「不是報告統計數字,不是舉行會議,而是像救主那樣,一次幫助一個 人,看看是否能夠藉著提升、鼓勵,最後改變他。」8

支聯會或支會教友有時會被要求去做過多且無效率的事情,支聯會會長團和主教團需要運用他們的權柄,去革除這些事情。教會的計畫應著重於最能夠(最有效)達成指派目標的事上,才不會過度侵犯家庭需要花在本身「神所指定的職責」之時間。

不 過家庭也要注意一件事,假設教會領袖減少了教會聚會和活動的時間,好讓家庭有更多時間在一起,除非每個家庭成員──特別是父母──積極地增進家人在一起的 時間及一對一的時間,否則還是無法達成預定的目標。團隊運動及電視遊戲和網路等科技電玩,早已佔據了我們孩子和青少年的時間。在網路上瀏覽漫遊,不會比為 主服務或鞏固家庭來得好。有些男女青年不參加教會的男女青年活動,或是利用家庭時間跑去參加足球隊,或從事各種娛樂活動。有些年輕人過度追求娛樂而導致死 亡──靈性的死亡。

在個人及家庭時間的運用上,有較好的用法,也有最好的用法。我們需要放棄一些好的事情,來作其他更好或最好的選擇,如此便能培養出對主耶穌基督的信心,並且鞏固我們的家庭。

以下是好、更好、最好抉擇的一些其他例證:

屬於天父真實的教會,遵守祂的誡命,履行我們的一切職責,這些都是好的,但是若要符合「最好」的標準,就必須懷著愛心,不驕傲自大地去做這些事。就像有一首聖詩所說的,我們應該「以手足情誼相待」,9對我們影響所及的每個人表達愛心與關懷。

我 要對成千上萬的家庭教導教師和探訪教師建議,我們去拜訪被分派到的家庭固然很好;要是能在簡短的拜訪中教導教義和原則更好,而最好的是能讓我們所拜訪的某 些家庭在生活上有所改變。同樣的挑戰也適用於我們所舉行的眾多聚會上──舉行聚會固然好,能教導一項原則更好,但是最好的是聚會的結果能確實改善人們的生 活。

2008年將至,我們在麥基洗德聖職定額組和婦女會將使用新的研讀課程,我要再次提醒各位如何使用總會會長的教 訓這本書。經過多年受靈啟發的努力,我們發行了2008年版的約瑟‧斯密的教訓;而約瑟‧斯密是本福音期的第一位先知。這本書是教會叢書中很重要的一本。 過去,有些教師教課時只簡短地提一下總會會長的教訓中每章的內容,然後用自己選擇的資料來取代課程內容。課程也許教得很好,但作法卻不足取。福音教師是被 召喚來教導教會提供之靈感教材裡的特定主題。教師用約瑟‧斯密的教訓這本書最好的作法是,針對班員的需求,挑選和引用先知對這些原則所講的話,然後引導班 員討論如何在生活環境中運用這些原則。

我要為我們的天父作見證,我們是祂的子女,祂的計畫是為了讓我們有資格獲得 「永生,……神一切恩賜中最大的」(教約14:7;亦見76:51-59)。我要為耶穌基督作見證,祂的贖罪使我們得以獲得永生。我見證我們有先知戈登‧ 興格萊會長和他的副會長在領導我們,奉耶穌基督的名,阿們。

註:

1. Sears, Roebuck and Co. Catalog, Fall and Winter 1944--45, 316E.

2. Jared R. Anderson and William J. Doherty, “Democratic Community Initiatives: The Case of Overscheduled Children,” Family Relations, vol. 54 (Dec. 2005): 655.

3. Anderson and Doherty, Family Relations, 54:655.

4. See Nancy Gibbs, “The Magic of the Family Meal,” Time, June 12, 2006, 51--52; see also Sarah Jane Weaver, “Family Dinner,” Church News, Sept. 8, 2007, 5.

5. 「每個人都變得更好」,2002年11月,利阿賀拿,第100頁。

6. 1999年2月11日,總會會長團信函;printed in Church News, Feb. 27, 1999, 3。

7. “The Doctrinal Foundation of the Auxiliaries,” Worldwide Leadership Training Meeting, Jan. 10, 2004, 5, 7--8; see also Ensign, Aug. 2005, 62, 67.

8. 「你們聰明些吧」,2006年11月,利阿賀拿,第18-20頁。

9. “America the Beautiful,” Hymns, no. 338.

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Good, Better, Best

Elder Dallin H. Oaks
Of the Quorum of the Twelve Apostles

We have to forego some good things in order to choose others that are better or best because they develop faith in the Lord Jesus Christ and strengthen our families.

Elder Dallin H. OaksMost of us have more things expected of us than we can possibly do. As breadwinners, as parents, as Church workers and members, we face many choices on what we will do with our time and other resources.

I.

We should begin by recognizing the reality that just because something is good is not a sufficient reason for doing it. The number of good things we can do far exceeds the time available to accomplish them. Some things are better than good, and these are the things that should command priority attention in our lives.

Jesus taught this principle in the home of Martha. While she was "cumbered about much serving" (Luke 10:40), her sister, Mary, "sat at Jesus' feet, and heard his word" (v. 39). When Martha complained that her sister had left her to serve alone, Jesus commended Martha for what she was doing (v. 41) but taught her that "one thing is needful: and Mary hath chosen that good part, which shall not be taken away from her" (v. 42). It was praiseworthy for Martha to be "careful and troubled about many things" (v. 41), but learning the gospel from the Master Teacher was more "needful." The scriptures contain other teachings that some things are more blessed than others (see Acts 20:35; Alma 32:14–15).

A childhood experience introduced me to the idea that some choices are good but others are better. I lived for two years on a farm. We rarely went to town. Our Christmas shopping was done in the Sears, Roebuck catalog. I spent hours poring over its pages. For the rural families of that day, catalog pages were like the shopping mall or the Internet of our time.

Something about some displays of merchandise in the catalog fixed itself in my mind. There were three degrees of quality: good, better, and best. For example, some men’s shoes were labeled good ($1.84), some better ($2.98), and some best ($3.45).1

As we consider various choices, we should remember that it is not enough that something is good. Other choices are better, and still others are best. Even though a particular choice is more costly, its far greater value may make it the best choice of all.

Consider how we use our time in the choices we make in viewing television, playing video games, surfing the Internet, or reading books or magazines. Of course it is good to view wholesome entertainment or to obtain interesting information. But not everything of that sort is worth the portion of our life we give to obtain it. Some things are better, and others are best. When the Lord told us to seek learning, He said, "Seek ye out of the best books words of wisdom" (D&C 88:118; emphasis added).

II.

Some of our most important choices concern family activities. Many breadwinners worry that their occupations leave too little time for their families. There is no easy formula for that contest of priorities. However, I have never known of a man who looked back on his working life and said, "I just didn't spend enough time with my job."

In choosing how we spend time as a family, we should be careful not to exhaust our available time on things that are merely good and leave little time for that which is better or best. A friend took his young family on a series of summer vacation trips, including visits to memorable historic sites. At the end of the summer he asked his teenage son which of these good summer activities he enjoyed most. The father learned from the reply, and so did those he told of it. "The thing I liked best this summer," the boy replied, "was the night you and I laid on the lawn and looked at the stars and talked." Super family activities may be good for children, but they are not always better than one-on-one time with a loving parent.

The amount of children-and-parent time absorbed in the good activities of private lessons, team sports, and other school and club activities also needs to be carefully regulated. Otherwise, children will be overscheduled, and parents will be frazzled and frustrated. Parents should act to preserve time for family prayer, family scripture study, family home evening, and the other precious togetherness and individual one-on-one time that binds a family together and fixes children's values on things of eternal worth. Parents should teach gospel priorities through what they do with their children.

Family experts have warned against what they call "the overscheduling of children." In the last generation children are far busier and families spend far less time together. Among many measures of this disturbing trend are the reports that structured sports time has doubled, but children's free time has declined by 12 hours per week, and unstructured outdoor activities have fallen by 50 percent.2

The number of those who report that their "whole family usually eats dinner together" has declined 33 percent. This is most concerning because the time a family spends together "eating meals at home [is] the strongest predictor of children's academic achievement and psychological adjustment."3 Family mealtimes have also been shown to be a strong bulwark against children's smoking, drinking, or using drugs.4 There is inspired wisdom in this advice to parents: What your children really want for dinner is you.

President Gordon B. Hinckley has pleaded that we "work at our responsibility as parents as if everything in life counted on it, because in fact everything in life does count on it." He continued:

"I ask you men, particularly, to pause and take stock of yourselves as husbands and fathers and heads of households. Pray for guidance, for help, for direction, and then follow the whisperings of the Spirit to guide you in the most serious of all responsibilities, for the consequences of your leadership in your home will be eternal and everlasting."5

The First Presidency has called on parents "to devote their best efforts to the teaching and rearing of their children in gospel principles. . . . The home is the basis of a righteous life, and no other instrumentality can take its place . . . in . . . this God-given responsibility." The First Presidency has declared that "however worthy and appropriate other demands or activities may be, they must not be permitted to displace the divinely-appointed duties that only parents and families can adequately perform."6

III.

Church leaders should be aware that Church meetings and activities can become too complex and burdensome if a ward or a stake tries to have the membership do everything that is good and possible in our numerous Church programs. Priorities are needed there also.

Members of the Quorum of the Twelve have stressed the importance of exercising inspired judgment in Church programs and activities. Elder L. Tom Perry taught this principle in our first worldwide leadership training meeting in 2003. Counseling the same leaders in 2004, Elder Richard G. Scott said: "Adjust your activities to be consistent with your local conditions and resources. . . . Make sure that the essential needs are met, but do not go overboard in creating so many good things to do that the essential ones are not accomplished. . . . Remember, don't magnify the work to be done—simplify it."7

In general conference last year, Elder M. Russell Ballard warned against the deterioration of family relationships that can result when we spend excess time on ineffective activities that yield little spiritual sustenance. He cautioned against complicating our Church service "with needless frills and embellishments that occupy too much time, cost too much money, and sap too much energy. . . . The instruction to magnify our callings is not a command to embellish and complicate them. To innovate does not necessarily mean to expand; very often it means to simplify. . . . What is most important in our Church responsibilities," he said, "is not the statistics that are reported or the meetings that are held but whether or not individual people—ministered to one at a time just as the Savior did—have been lifted and encouraged and ultimately changed."8

Stake presidencies and bishoprics need to exercise their authority to weed out the excessive and ineffective busyness that is sometimes required of the members of their stakes or wards. Church programs should focus on what is best (most effective) in achieving their assigned purposes without unduly infringing on the time families need for their "divinely appointed duties."

But here is a caution for families. Suppose Church leaders reduce the time required by Church meetings and activities in order to increase the time available for families to be together. This will not achieve its intended purpose unless individual family members—especially parents—vigorously act to increase family togetherness and one-on-one time. Team sports and technology toys like video games and the Internet are already winning away the time of our children and youth. Surfing the Internet is not better than serving the Lord or strengthening the family. Some young men and women are skipping Church youth activities or cutting family time in order to participate in soccer leagues or to pursue various entertainments. Some young people are amusing themselves to death—spiritual death.

Some uses of individual and family time are better, and others are best. We have to forego some good things in order to choose others that are better or best because they develop faith in the Lord Jesus Christ and strengthen our families.

IV.

Here are some other illustrations of good, better, and best:

It is good to belong to our Father in Heaven's true Church and to keep all of His commandments and fulfill all of our duties. But if this is to qualify as "best," it should be done with love and without arrogance. We should, as we sing in a great hymn, "crown [our] good with brotherhood,"9 showing love and concern for all whom our lives affect.

To our hundreds of thousands of home teachers and visiting teachers, I suggest that it is good to visit our assigned families; it is better to have a brief visit in which we teach doctrine and principle; and it is best of all to make a difference in the lives of some of those we visit. That same challenge applies to the many meetings we hold—good to hold a meeting, better to teach a principle, but best to actually improve lives as a result of the meeting.

As we approach 2008 and a new course of study in our Melchizedek Priesthood quorums and Relief Societies, I renew our caution about how we use the Teachings of Presidents of the Church manuals. Many years of inspired work have produced our 2008 volume of the teachings of Joseph Smith, the founding prophet of this dispensation. This is a landmark among Church books. In the past, some teachers have given a chapter of the Teachings manuals no more than a brief mention and then substituted a lesson of their own choice. It may have been a good lesson, but this is not an acceptable practice. A gospel teacher is called to teach the subject specified from the inspired materials provided. The best thing a teacher can do with Teachings: Joseph Smith is to select and quote from the words of the Prophet on principles specially suited to the needs of class members and then direct a class discussion on how to apply those principles in the circumstances of their lives.

I testify of our Heavenly Father, whose children we are and whose plan is designed to qualify us for "eternal life . . . the greatest of all the gifts of God" (D&C 14:7; see also D&C 76:51–59). I testify of Jesus Christ, whose Atonement makes it possible. And I testify that we are led by prophets, our President Gordon B. Hinckley and his counselors, in the name of Jesus Christ, amen.


NOTES
1. Sears, Roebuck and Co. Catalog, Fall and Winter 1944–45, 316E.
2. Jared R. Anderson and William J. Doherty, "Democratic Community Initiatives: The Case of Overscheduled Children," Family Relations, vol. 54 (Dec. 2005): 655.
3. Anderson and Doherty, Family Relations, 54:655.
4. See Nancy Gibbs, "The Magic of the Family Meal," Time, June 12, 2006, 51–52; see also Sarah Jane Weaver, "Family Dinner," Church News, Sept. 8, 2007, 5.
5. "Each a Better Person," Liahona and Ensign, Nov. 2002, 100.
6. First Presidency letter, Feb. 11, 1999; printed in Church News, Feb. 27, 1999, 3.
7. "The Doctrinal Foundation of the Auxiliaries," Worldwide Leadership Training Meeting, Jan. 10, 2004, 5, 7–8; see also Ensign, Aug. 2005, 62, 67.
8. "O Be Wise," Liahona and Ensign, Nov. 2006, 18–20.
9. "America the Beautiful," Hymns, no. 338.

About Me

我是在1996年12月29日受洗加入耶穌基督後期聖徒教會. 我在此留下我對這復興的福音的見證,我知道約瑟斯密確實是神的先知; 藉由約瑟斯密,神復興了耶穌基督的教會即耶穌基督後期聖徒教會; 摩爾門經是耶穌基督的另一部約書,與聖經共同見證耶穌是基督.而我們今日仍有一位活著的先知,多馬孟蓀會長 I joined the Church of Jesus Christ of Latter-day Saints on December 29, 1996. I know that Joseph Smith was and is a prophet of God. The Book of Mormon is indeed Another Testament of Jesus Christ. We have a living prophet today, even President Thomas S. Monson.

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