請用此 Handle URI 來引用此文件:
http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/56157
完整後設資料紀錄
DC 欄位 | 值 | 語言 |
---|---|---|
dc.contributor.advisor | 蕭斐元 | |
dc.contributor.author | Chen-Yu Wang | en |
dc.contributor.author | 王貞予 | zh_TW |
dc.date.accessioned | 2021-06-16T05:17:14Z | - |
dc.date.available | 2019-10-15 | |
dc.date.copyright | 2014-10-15 | |
dc.date.issued | 2014 | |
dc.date.submitted | 2014-08-15 | |
dc.identifier.citation | 1. Bates ER, Lau WC, Angiolillo DJ. Clopidogrel-drug interactions. Journal of the American College of Cardiology 2011;57:1251-63.
2. Tentzeris I, Siller-Matula J, Farhan S, Jarai R, Wojta J, Huber K. Platelet function variability and non-genetic causes. Thrombosis and haemostasis 2011;105 Suppl 1:S60-6. 3. Lloyd-Jones D, Adams RJ, Brown TM, et al. Executive summary: heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation 2010;121:948-54. 4. Anderson JL, Adams CD, Antman EM, et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology 2013;61:e179-347. 5. Kushner FG HM, Smith SC Jr, et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update). Circulation 2009 120:2271-306. 6. Huynh T, Perron S, O'Loughlin J, et al. Comparison of primary percutaneous coronary intervention and fibrinolytic therapy in ST-segment-elevation myocardial infarction: bayesian hierarchical meta-analyses of randomized controlled trials and observational studies. Circulation 2009;119:3101-9. 7. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation 2004;110:588-636. 8. Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the Canadian Cardiovascular Society Endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation 2007;117:296-329. 9. Mahoney M JC, Chu H, et al. Cost and cost-effectiveness of an early invasive vs conservative strategy for the treatment of unstable angina and non-ST-segment elevation myocardial infarction. JAMA 2002;288. 10. Yusuf S ZF, Meta SR, et al. . Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. . The New England journal of medicine 2001;345:494-502. 11. Mehta SR, Yusuf S, Peters RJG, et al. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. The Lancet 2001;358:527-33. 12. Steinhubl SR, Berger PB, Mann Iii JT, et al. Early and Sustained Dual Oral Antiplatelet Therapy Following Percutaneous Coronary Intervention. Jama 2002;288:2411. 13. Doppler flow and echocardiography in functional cardiac insufficiency: assessment of nisoldipine therapy. Results of the DEFIANT-II Study. The DEFIANT-II Research Group. European heart journal 1997;18:31-40. 14. Group TD-IR. Doppler flow and echocardiography in functional cardiac insufficiency: Assessment of nisoldipine therapy. European heart journal 1997;18:31-40. 15. Fischer Hansen LH, Bjarne Sigurd,. Cardiac Event Rates After Acute Myocardial Infarction in Patients Treated With Verapamil and Trandolapril Versus Trandolapril Alone. The American journal of cardiology 1997;79:738-41. 16. The effect of diltiazem on mortality and reinfarction after myocardial infarction. The Multicenter Diltiazem Postinfarction Trial Research Group. The New England journal of medicine 1988;319:385-92. 17. Ishikawa K, Nakai S, Takenaka T, et al. Short-acting nifedipine and diltiazem do not reduce the incidence of cardiac events in patients with healed myocardial infarction. Secondary Prevention Group. Circulation 1997;95:2368-73. 18. Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II--DAVIT II). The American journal of cardiology 1990;66:779-85. 19. Rengo F, Carbonin P, Pahor M, et al. A controlled trial of verapamil in patients after acute myocardial infarction: results of the calcium antagonist reinfarction Italian study (CRIS). The American journal of cardiology 1996;77:365-9. 20. DARRELL B, JANICE B. S CHWARTZ. CALCIUM-ANTAGONIST DRUGS. The New England J of Medicine 1999;341. 21. Boden WE, van Gilst WH, Scheldewaert RG, et al. Diltiazem in acute myocardial infarction treated with thrombolytic agents: a randomised placebo-controlled trial. The Lancet 2000;355:1751-6. 22. Fefer P, Hod H, Matetzky S. Clopidogrel resistance--the cardiologist's perspective. Platelets 2007;18:175-81. 23. Siller-Matula J, Schror K, Wojta J, Huber K. Thienopyridines in cardiovascular disease: focus on clopidogrel resistance. Thrombosis and haemostasis 2007;97:385-93. 24. Weerakkody GJ, Brandt JT, Payne CD, Jakubowski JA, Naganuma H, Winters KJ. Clopidogrel poor responders: an objective definition based on Bayesian classification. Platelets 2007;18:428-35. 25. Snoep JD, Hovens MM, Eikenboom JC, van der Bom JG, Jukema JW, Huisman MV. Clopidogrel nonresponsiveness in patients undergoing percutaneous coronary intervention with stenting: a systematic review and meta-analysis. American heart journal 2007;154:221-31. 26. Siller-Matula JM, Lang I, Christ G, Jilma B. Calcium-channel blockers reduce the antiplatelet effect of clopidogrel. Journal of the American College of Cardiology 2008;52:1557-63. 27. Gremmel T, Steiner S, Seidinger D, Koppensteiner R, Panzer S, Kopp CW. Calcium-channel blockers decrease clopidogrel-mediated platelet inhibition. Heart 2010;96:186-9. 28. Harmsze AM, Robijns K, van Werkum JW, et al. The use of amlodipine, but not of P-glycoprotein inhibiting calcium channel blockers is associated with clopidogrel poor-response. Thrombosis and haemostasis 2010;103:920-5. 29. Yan G. Effect of clopidogrel combined with calcium-channel blocker on coronary artery disease in elderly patients: a propensity score-based retrospective cohort study. 南方医科大学学报(J South Med Univ) 2012;32(4). 30. Peng Y, Chen M, Chai H, et al. Impact of combination of calcium-channel blockers with clopidogrel on clinical outcomes in patients with coronary artery disease. International journal of cardiology 2011;149:274-6. 31. Sarafoff N, Neumann L, Morath T, et al. Lack of impact of calcium-channel blockers on the pharmacodynamic effect and the clinical efficacy of clopidogrel after drug-eluting stenting. American heart journal 2011;161:605-10. 32. Olesen JB, Gislason GH, Charlot MG, et al. Calcium-channel blockers do not alter the clinical efficacy of clopidogrel after myocardial infarction: a nationwide cohort study. Journal of the American College of Cardiology 2011;57:409-17. 33. Lee S-P, Bae J-W, Park KW, et al. Inhibitory Interaction Between Calcium Channel Blocker and Clopidogrel. Circulation Journal 2011;75:2581-9. 34. Good CW, Steinhubl SR, Brennan DM, Lincoff AM, Topol EJ, Berger PB. Is there a clinically significant interaction between calcium channel antagonists and clopidogrel?: results from the Clopidogrel for the Reduction of Events During Observation (CREDO) trial. Circulation Cardiovascular interventions 2012;5:77-81. 35. Andrew Y W Li F-HN, Francis K L Chan et al. Effect of amlodipine on platelet inhibition by clopidogrel in patients with ischaemic heart disease: a randomised, controlled trial. Heart 2013;99:468-73. 36. Park KW, Kang J, Park JJ, et al. Amlodipine, clopidogrel and CYP3A5 genetic variability: effects on platelet reactivity and clinical outcomes after percutaneous coronary intervention. Heart 2012;98:1366-72. 37. Park JJ, Park KW, Kang J, et al. CYP3A4 Genetic Status May Be Associated With Increased Vulnerability to the Inhibitory Effect of Calcium-Channel Blockers on Clopidogrel. Circulation Journal 2013;77:1289-96. 38. Taubert D, von Beckerath N, Grimberg G, et al. Impact of P-glycoprotein on clopidogrel absorption. Clinical pharmacology and therapeutics 2006;80:486-501. 39. Zhou SF, Xue CC, Yu XQ, Li C, Wang G. Clinically important drug interactions potentially involving mechanism-based inhibition of cytochrome P450 3A4 and the role of therapeutic drug monitoring. Therapeutic drug monitoring 2007;29:687-710. 40. Machavaram KK, Gundu J, Yamsani MR. Effect of various cytochrome P450 3A and P-glycoprotein modulators on the biliary clearance of bromosulphaphthalein in male wistar rats. Die Pharmazie 2004;59:957-60. 41. Crosta L, Candiloro V, Meli M, Tolomeo M, Rausa L, Dusonchet L. Lacidipine and josamycin: two new multidrug resistance modulators. Anticancer research 1994;14:2685-9. 42. Klotz U. Interaction potential of lercanidipine, a new vasoselective dihydropyridine calcium antagonist. Arzneimittel-Forschung 2002;52:155-61. 43. KU P. Evaluation of pharmacokinetic drug-drug-interactions. Critical considerations of the relevance of pharmacokinetic drug-drug interactions of proton pump inhibitors in self medication. Med Monatsschr Pharm 2011 Aug;34(8):270-8. 44. Ye-Jee Kim N-KC, Jong-Mi Seong et al. Impact of concomitant use of proton pump inhibitors and dual antiplatelet therapy on recurrent myocardial infraction. 8th Asian Conference on Pharmacoepidemiology 2013; Hong Kong: International Society for Pharmacoepidemiology 2013. p. 48. 45. Wessler JD, Grip LT, Mendell J, Giugliano RP. The P-glycoprotein transport system and cardiovascular drugs. Journal of the American College of Cardiology 2013;61:2495-502. 46. Li W, Zeng S, Yu LS, Zhou Q. Pharmacokinetic drug interaction profile of omeprazole with adverse consequences and clinical risk management. Therapeutics and clinical risk management 2013;9:259-71. 47. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Journal of the American College of Cardiology 2007;50:e1-e157. | |
dc.identifier.uri | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/56157 | - |
dc.description.abstract | 研究背景:
相關研究顯示併用calcium channel blockers (CCBs)會降低clopidogrel抑制血小板活性的效果,然而連結臨床結果之研究不足且能提供的資訊相當有限。 研究目的: 分析併用CCBs和clopidogrel是否會影響clopidogrel的臨床效益。為使研究結果更能符合臨床需求,本研究進一步探討在不同CCBs持有率(MPR:Medication possession ratio)、不同CCBs之種類和成分的情況下,對於clopidogrel臨床效益之影響是否存在差異。 研究方法: 本研究為一回溯性世代研究,利用2005-2011年台灣健保資料庫為資料來源,收集因第一次急性冠心症(ACS: acute coronary syndrome)住院並接受經皮冠狀動脈介入術(PCI: percutaneous coronary intervention)之病人,同時符合出院後一年內有使用dual antiplatelet therapy的族群。進一步依照出院後使用美國心臟醫學會及心臟協會治療指引建議之ACS二次預防藥物(包含:β-blockers、(ACEI/ARB: Angiotensin-converting enzyme inhibitor /Angiotensin receptor blocker)、statins)之情形,將病人分成三組。其中完全符合guideline組為使用三種預防藥物之病人,部分符合guideline組為使用一至二種預防藥物之病人,不符合guideline組為完全沒有使用二次預防藥物之病人。同時為了縮小自我選擇偏差,本研究利用傾向分數(propensity score)配對的方式,將使用CCBs的病人1:1配對找出沒有使用CCB的對照組。以Cox proportional hazard model 來分析追蹤期間CCBs的使用,對於clopidogrel預防ACS再住院效果之影響。本研究進一步將CCBs依MPR高低分組,以探討藥品使用量與研究終點之關係。另外,依CCBs之化學結構將其分成Dihydropyridine CCBs和Non-Dihydropyridine CCBs;以及對Pgp(P-glycoprotein)的抑制情形分成以Pgp-inhibiting CCBs和Non-Pgp-inhibiting CCBs分別探討不同種類CCBs之差異。最後,探討國內六種常用成分之CCBs的各別結果。 研究結果: 本研究共收納51925位病人,經過傾向分數配對後,完全符合guideline組使用CCB者與對照組人數比例為5374:5374 ; 部分符合組11164:11164;不符合組923:923。在校正過性別、年齡、共併症和併用藥物的影響過後,使用CCB的族群發生ACS再入院之風險較未使用CCB的族群低,此現象在各組均有相同結果。(完全符合組: HR=0.62 ( 95%CI =0.57-0.68, p<0.001); 部分符合組: HR=0.72 (0.68-0.76, p<0.001);不符合組: HR=0.79 (0.66-0.94, p=0.0073))。 另外,CCBs的藥物持有率增加時,發生ACS再住院之風險也隨之上升,此現象在各組都有相同趨勢(於完全符合組: 0<MPR<=0.3, HR=0.56 ( 0.5-0.57, p<0.001 ); 0.3<MPR<=0.7, HR=0.50 (0.44-0.60, p<0.001);0.7<MPR<1, HR=0.68 (0.60-0.77, p<0.001);MPR>=1, HR=0.76 (0.67-0.81, p<0.001))。進一步分析不同種類之CCBs的結果時,發現Dihydropyridine類CCBs相較於Non-Dihydropyridine類CCBs,有較低之ACS再住院風險(完全符合組: HR=0.71 (0.60-0.84, p<0.001); 部分符合組: HR=0.77 (0.70-0.85, p<0.001);不符合組: HR=0.82 (0.57-1.04, p=0.166))。而Pgp-inhibiting CCBs 相較於Non-Pgp- inhibiting CCBs 有較高的ACS再住院風險(完全符合組: HR= 1.23 ( 95%CI =1.07-1.41, p=0.003); 部分符合組: HR=1.14 ( 1.05-1.24, p=0.002);不符合組: HR=1.37 (1.02-1.83, p=0.034)); 最後,分析單一成分時,發現國內最常用之六種CCBs成分(amlodipine、felodipine、nifedipine、 verapamil、diltiazem、lercanidipine), 只有amlodipine的使用,在各組都能顯著降低ACS再住院之風險。反之,felodipine 在不符合guideline組的使用,相較於沒有使用CCB的對照組則會顯著上升ACS再住院之風險。 研究結論: 在使用二次預防藥物的情形下併用CCBs和clopidogrel不會下降ACS病人進行PCI之後使用clopidogrel的臨床效益。而CCBs和clopidogrel潛在交互作用方面,可能和CCBs的持有率存在一個dose-dependent的關係。在沒有使用任何ACS二次預防藥物的情形下,併用felodipine這個成分,則會顯著下降clopidogrel的臨床效益。此外,ACS之後病人存在多樣性,因此做相關藥物分析時建議分開探討且CCBs之各成分也有其不同臨床特性,不可視為單一種類等同視之 | zh_TW |
dc.description.abstract | Background: Existing studies have reported that calcium channel blockers (CCBs) may reduce pharmacological activity of clopidogrel and result in subsequent negative outcomes. However, studies assessing clinical outcomes in patients receiving both drugs are very limited.
Objectives: The objective of this population-based cohort study was therefore to investigate risks of recurrent hospitalization for acute coronary syndrome (ACS) in patients receiving percutaneous coronary intervention (PCI) who require ongoing dual antiplatelet therapy (aspirin + clopidogrel) with or without CCBs. Furthermore, we assess the outcome of medication possession ratio (MPR) of CCBs, different category of CCBs and individual component. Methods: Using 2005-2011 Taiwan's National Health Insurance Research Database, we identified 51925 patients who first admitted for ACS, received PCI and used dual antiplatelet therapy within one year after they discharged. We further divided our study population into three subgroups based on the medication categories they used for secondary prevention for ACS, including β-blockers, ACEI (angiotensin-converting enzyme inhibitor)/ARB (angiotensin receptor blocker) and statins. Completely, partially and non- adherent groups consisted of patients using three categories, one or two categories and none of medications for secondary prevention, respectively. In order to minimize the variation between individual characteristics, we conduct 1:1 propensity score matching. Cox proportional hazard model were conducted to assess re-hospitalization for ACS in patients receiving clopidogrel therapy with or without CCBs. Forthermore, we use the MPR to assess the relationship between the amount of CCBs use and ACS re-hospitalization. We separate CCBs by their chemical structure as Dihydropyridine CCBs and Non-Dihydropyrydyne; and by their P-glycoprotein(Pgp) inhibiting property as Pgp-inhibiting CCBs and Non-Pgp-inhibiting CCBs, in order to assess the different of this two category CCBs. Finally, we assess the outcomes of the six most frequently use CCBs in Taiwan. Results: Among clopidogrel users, concomitant use of CCBs was associated with a reduced hazard of re-hospitalization for ACS after adjusting for age, gender, co-morbidities, and co-medications (completely-adherent group: HR=0.62 (95% CI 0.57-0.68, p<0.001);partially-adherent group: HR=0.72 (0.68-0.76, p<0.001);none-adherent group: HR=0.79 (0.66-0.94, p=0.0073)). When the MPR increased, the risk of re-hospitalization for ACS increased in all subgroups. (completely-adherent group: 0<MPR<=0.3, HR=0.56 (0.5-0.57, p<0.001 ); 0.3<MPR<=0.7, HR=0.50 (0.44-0.60, p<0.001);0.7<MPR<1, HR=0.68 (0.60-0.77, p<0.001);MPR>=1, HR=0.76 (0.67-0.81, p<0.001))。 In comparison with Dihydropyridine CCBs, Non-Dihydropyridine CCBs were associated with a higher hazard of re-hospitalization for ACS. (completely-adherent group: HR=1.41 (1.19-1.68, p<0.001); partially-adherent group: HR=1.30 (1.18-1.44, p<0.001);none-adherent group: HR=1,22 (0.92-1.61, p=0.166)) And, amlodipine was associated with lower risk of ACS rehospitalization in all three subgroups, while felodipine was associated with higher risk of ACS rehospitalization in group of none apply to guideline. Conclusion: This population-based cohort study found that concomitant use of clopidogrel and CCBs in patients who received PCI after ACS was not associated with an increasing risk of recurrent hospitalization. However, CCBs medication possession ratio and concomitance use of clopidogrel and felodipine in patients without secondary prevention medications may affect the risk of ACS rehospitalization. | en |
dc.description.provenance | Made available in DSpace on 2021-06-16T05:17:14Z (GMT). No. of bitstreams: 1 ntu-103-R01451007-1.pdf: 923238 bytes, checksum: 5de780ab1fded3d3094aa699170c80c7 (MD5) Previous issue date: 2014 | en |
dc.description.tableofcontents | 摘要 i
Abstract iii 目錄 v 表目錄 vii 圖目錄 viii 附錄目錄 ix 第一章 前言 2 第一節 研究背景與現況 2 第二節 研究目的與問題 3 第三節 研究重要性 3 第二章 文獻探討 4 第一節 急性冠心症 (ACS, Acute coronary syndrome) 4 第二節 急性冠心症之二次預防 4 第三節 Clopidogrel於ACS病人的角色 5 第四節 Calcium Channel Blockers於ACS病人的角色 7 第五節 CCBs 和clopidogrel交互作用相關研究回顧 9 第三章 研究方法 16 第一節 研究材料 16 第二節 研究設計 16 3.2.1研究族群納入與排除條件 18 3.2.2追蹤期間定義 20 3.2.3研究終點定義: 20 3.2.4 研究對象分組與配對 21 第三節 研究變項 23 3.3.1共變數 23 3.3.2 主要探討藥物 - CCBs之使用情形 26 第四節 統計分析 27 3.4.1 描述性統計分析 27 3.4.2 研究終點事件之推論性統計 27 第四章 研究結果 28 第一節 研究族群的建立與基本特性分析 28 4.1.1新住院診斷為ACS且接受PCI之病人族群 28 4.1.2 研究族群依二次預防用藥使用情形分組結果 28 4.1.3 各組別基本特性分析 30 第二節 研究族群之配對與CCBs使用情形 32 4.2.1 各組進行propensity score matching的結果與基本特性分析 32 4.2.2關於各組別使用CCBs的情況 36 第三節 CCBs的使用與研究終點之關係 37 4.3.1 CCBs的使用與各種研究終點的關係 37 4.3.2 CCBs的持有率和ACS再住院之風險相關性 38 4.3.3 不同種類CCBs和ACS再住院之風險相關性 39 4.3.4 各種不同成分之CCBs和ACS再住院之風險相關性 40 第五章 討論與結論 42 第一節 本研究之結果與過去文獻之異同 42 第二節 併用CCBs對於clopidogrel臨床效益之影響 44 5.2.1 不同CCBs之持有率與clopidogrel臨床效益之關係 44 5.2.2不同種類CCBs的使用與clopidogrel臨床效益之關係 45 5.2.3不同成分CCBs的使用與clopidogrel臨床效益之關係 48 第三節 研究限制與優點特色 49 5.3.1 研究限制 49 5.3.2 研究優點特色 50 第四節 結論與建議 51 參考文獻 52 附錄 57 | |
dc.language.iso | zh-TW | |
dc.title | 急性冠心症病人使用雙重抗血小板藥物併用鈣離子阻斷劑與再發生心血管事件之分析 | zh_TW |
dc.title | Concomitant use of Calcium Channel Blockers with Dual Antiplatelet Therapy and Recurrent Cardiovascular Events for Patients with Acute Coronary Syndrome after Percutaneous Coronary Intervention | en |
dc.type | Thesis | |
dc.date.schoolyear | 102-2 | |
dc.description.degree | 碩士 | |
dc.contributor.coadvisor | 林珍芳 | |
dc.contributor.oralexamcommittee | 李啟明,沈麗娟,蔡憶文 | |
dc.subject.keyword | clopidogrel藥物交互作用,鈣離子阻斷劑,急性冠心症,經皮冠狀動脈介入術,再住院, | zh_TW |
dc.subject.keyword | clopidogrel drug interaction,calcium cahnnel blockers,acute coronary syndrome,percutaneous coronary interventio,rehospitalization, | en |
dc.relation.page | 67 | |
dc.rights.note | 有償授權 | |
dc.date.accepted | 2014-08-18 | |
dc.contributor.author-college | 醫學院 | zh_TW |
dc.contributor.author-dept | 臨床藥學研究所 | zh_TW |
顯示於系所單位: | 臨床藥學研究所 |
文件中的檔案:
檔案 | 大小 | 格式 | |
---|---|---|---|
ntu-103-1.pdf 目前未授權公開取用 | 901.6 kB | Adobe PDF |
系統中的文件,除了特別指名其著作權條款之外,均受到著作權保護,並且保留所有的權利。