Expert clinical reasoning and pain assessment in mechanically ventilated patients: A descriptive study.

BACKGROUND: Pain assessment in mechanically ventilated patients is challenging, because nurses need to decode pain behaviour, interpret pain scores, and make appropriate decisions. This clinical reasoning process is inherent to advanced nursing practice, but is poorly understood. A better understanding of this process could contribute to improved pain assessment and management. OBJECTIVE: This study aimed to describe the indicators that influence expert nurses' clinical reasoning when assessing pain in critically ill nonverbal patients. METHODS: This descriptive observational study was conducted in the adult intensive care unit (ICU) of a tertiary referral hospital in Western Switzerland. A purposive sample of expert nurses, caring for nonverbal ventilated patients who received sedation and analgesia, were invited to participate in the study. Data were collected in "real life" using recorded think-aloud combined with direct non-participant observation and brief interviews. Data were analysed using deductive and inductive content analyses using a theoretical framework related to clinical reasoning and pain. RESULTS: Seven expert nurses with an average of 7.85 (±3.1) years of critical care experience participated in the study. The patients had respiratory distress (n=2), cardiac arrest (n=2), sub-arachnoid bleeding (n=1), and multi-trauma (n=2). A total of 1344 quotes in five categories were identified. Patients' physiological stability was the principal indicator for making decision in relation to pain management. Results also showed that it is a permanent challenge for nurses to discriminate situations requiring sedation from situations requiring analgesia. Expert nurses mainly used working knowledge and patterns to anticipate and prevent pain. CONCLUSIONS: Patient's clinical condition is important for making decision about pain in critically ill nonverbal patients. The concept of pain cannot be assessed in isolation and its assessment should take the patient's clinical stability and sedation into account. Further research is warranted to confirm these results.

Integration of Economics into Life Cycle Assessment in the Finnish Pulp and Paper Industry

Taloudellisen laskennan yhdistäminen elinkaariarviointiin (LCA) on alkanut kiinnostaa eri teollisuuden aloja maailmanlaajuisesti viime aikoina. Useat LCA-tietokoneohjelmat sisältävät kustannuslaskentaominaisuuksia ja yksittäiset projektit ovat yhdistäneet ympäristö- ja talouslaskentamenetelmiä. Tässä projektissa tutkitaan näiden yhdistelmien soveltuvuutta suomalaiselle sellu- ja paperiteollisuudelle, sekä kustannuslaskentaominaisuuden lisäämistä KCL:n LCA-ohjelmaan, KCL-ECO 3.0:aan. Kaikki tutkimuksen aikana löytyneet menetelmät, jotka yhdistävät LCA:n ja taloudellista laskentaa, on esitelty tässä työssä. Monet näistä käyttävät elinkaarikustannusarviointia (LCCA). Periaatteessa elinkaari määritellään eri tavalla LCCA:ssa ja LCA:ssa, mikä luo haasteita näiden menetelmien yhdistämiselle. Sopiva elinkaari tulee määritellä laskennan tavoitteiden mukaisesti. Työssä esitellään suositusmenetelmä, joka lähtee suomalaisen sellu- ja paperiteollisuuden erikoispiirteistä. Perusvaatimuksena on yhteensopivuus tavanomaisesti paperin LCA:ssa käytetyn elinkaaren kanssa. Menetelmän yhdistäminen KCL-ECO 3.0:aan on käsitelty yksityiskohtaisesti.

Evaluation du risque de récidive dans les expertises pénales: quels outils? Quets indicateurs? Quelles pratiques [Risk assessment in forensic psychiatric reports: what kind assessment instrument? What indicator? What practical?].

Here we present results of studies conducted by the Research Unit of Legal Psychiatry and Psychology of Lausanne about risk assessment and protective factors in the evaluation of violence recidivism. It aims to help experts in considering the relevance and use of tools at their disposal. Particular attention is given to the significance of protective factors and impulsive dimensions, as to the inter-raters process that leads to the final deliberations.

Example of Monte Carlo uncertainty assessment in the field of radionuclide metrology

This chapter presents possible uses and examples of Monte Carlo methods for the evaluation of uncertainties in the field of radionuclide metrology. The method is already well documented in GUM supplement 1, but here we present a more restrictive approach, where the quantities of interest calculated by the Monte Carlo method are estimators of the expectation and standard deviation of the measurand, and the Monte Carlo method is used to propagate the uncertainties of the input parameters through the measurement model. This approach is illustrated by an example of the activity calibration of a 103Pd source by liquid scintillation counting and the calculation of a linear regression on experimental data points. An electronic supplement presents some algorithms which may be used to generate random numbers with various statistical distributions, for the implementation of this Monte Carlo calculation method.

Référentiel de pratiques professionnelles: soins et surveillance des accès veineux centraux de l'adulte pour la nutrition parentérale [Formative assessment in clinical nutrition: Care management of parenteral nutrition central venous access]

Les voies veineuses centrales (VVC) sont essentielles pour l'administration de la nutrition parentérale. Le risque de complications est dépendant de la qualité des soins apportés à la VVC qui influence de ce fait la qualité de vie des patients et le coût des soins. Beaucoup de complications des VVC, infectieuses ou non, peuvent être prévenues par l'existence de protocoles de soins appropriés et standardisés. L'information sur les soins des VVC et les éventuelles complications est essentielle pour le dépistage et le traitement précoce de ces complications ; elle doit faire l'objet de protocoles partagés entre les patients et les soignants. Cet article décrit une évaluation des pratiques professionnelles sous la forme d'un audit clinique destiné à améliorer la qualité de soins des patients en nutrition parentérale porteurs de VVC. Central venous access devices (CVAD) are essential for the administration of parenteral nutrition. The quality of the care of CVAD influences the risk of complications and so the quality of life of the patients and the costs of care. Numerous infectious or non-infectious complications of CVAD can be prevented by appropriate, standardized protocols of care. Information about the care of CVAD and complications is essential for the early recognition and treatment of complications and should be shared between patients and caregivers. This article describes an audit for CAVD care that can be used to improve quality of care in a professional practice evaluation program.

Assessment in CLIL

The aim of this talk is to explore assessment in higher education and support for learners during their academic education. It investigates the assessment methods that provide success for universities and learners. Universities which implement CLIL should assess learners who would like to attend a programme in English without taking account of their English language qualifications. This assessment should be done in writing, listening and comprehension, speaking and reading and comprehension. In the literature, formative and summative assessments are considered. Formative assessment is ongoing, 'more complex as its intention is to be directly diagnostics with a view to immediately impacting on learner's next steps' (Coyle et al, 2010). Summative assessment occurs at the end of the term or course. McKay, 2006 divides assessment into three phases: design, operationalization and administration phase. If these three phases can't be embedded in the classroom as they are, they can be introduced as a set of questions; why?, how? and what?

Reliability of intraoperative ultrasound in margin status assessment in women undergoing breast conserving surgery

Background: Effective treatment for breast cancer requires accurate preoperative planning, developing and implementing a consistent definition of margin clearance, and using tools that provide detailed real-time intraoperative information on margin status. Intraoperative ultrasound (IOUS) may fulfil these requirements and may offer few advantages that other preoperative localization and intraoperative margin assessment techniques may notPurpose: The goal of the present work is to determine how accurate the intraoperative ultrasound should be to acquire complete surgical excision with negative histological margins in patients undergoing Breast Conservative SurgeryDesign: A diagnostic test study with a cross-sectional design carried out in a tertiary referral hospital in Girona within a Breast Pathology UnitParticipants: Women diagnosed with breast cancer undergoing a Breast Conservative Surgery in the Breast Pathology Unit at Hospital Universitari de Girona Dr. Josep Trueta

Digital learner portfolio as a tool for inovating assessment in the European Higher Education Area

The present article comes from a doctoral thesis that turns on digital learner portfolio, which is an innovating methodology from the perspective of European Higher Education Area. First, the educative concept of eportfolio is described in the sense of its procedure and its structure, by means of the technological support of a platform of virtual campus. Second, it is shown the pedagogical model of an eportfolio that adapts subjects with an instrumental character to one organization based on tasks and reflections. This design of virtual learning environment is based on a teaching- learning methodology sustained in the activity of the student, which tries to give support to the management of his or her own process of learning and assessment. Finally, the article illustrates the experience of implementation of the first digital learner portfolios in the University of Barcelona and the Autonomous University of Barcelona, with the objective of reflecting about the pedagogical consequences that this assessment model with technological support has in a traditional higher education institution.

¿Para qué sirven los problemas en la clase de matemáticas? = What is the use of problems in Mathematics lessons?

The results obtained in several yield tests, at an international level (mainly the famous PISA 2003 report, by the OCDE), have raised a multiplicity of performances in order to improve the students' yield regarding problem solving. In this article we set a clear guideline on how problems should be used in Mathematics lessons, not for obtaining better scores in the yield tests but for improving the development of Mathematical thinking in students. From this perspective, the author analyses, through eight reflections, how the concept of problem, transmitted both in the school and from society, influences the students

Electrocardiogram assessment in non-anaesthetized clinically healthy agouti (Dasyprocta primnolopha, Wagler 1831)

The agouti is one of the most intensely hunted species throughout the Amazon and the semiarid regions of north-eastern Brazil. Considering the current tendency of wild animal management in captivity, the objective of this study was to determine heart reference values for agouti raised in captivity, based on electrocardiographic assessments (ECG). Adult agouti were selected without clinical signs of heart disease (n=30). The animals were restrained physically and then the ECG was performed. Standardized measurements were taken to establish the statistical analysis of the data. Analysis of the QRS complex showed values compatible with previous reports in peer animals and the limited data available for other wild and exotic species, except for the T wave that showed similar amplitude to the R wave in all the animals studied. The data obtained provided the first reference values for ECG tracings in agouti, contributing to a better understanding of heart electrophysiology in identifying myocardial pathology in these animals.

Customer value assessment in business markets

Understanding how firms create, communicate, and deliver value to customers is a key factor when firms seek to differentiate in increasingly competitive and commoditized business markets. As product and price have become less important differentiators in many industries, suppliers are increasingly seeking ways to differentiate themselves based on delivered customer value. Therefore, to gain a holistic understanding on what their offerings are worth to the customer, suppliers need to conduct customer value assessment, which quantifies the impact of a supplier´s offering to customers’ costs and returns. However, from a managerial perspective, customer value assessment is the single most critical challenge for firms in business markets. Consequently, developing holistic frameworks for customer value assessment is seen as one of the most important research priorities for marketing research. The purpose of this study is to explore the process of customer value assessment in business markets. Business markets represent a context where an increasing number of industrial firms are transitioning from basic product offerings towards service-based and solution-oriented hybrid offerings, which emphasize value co-creation and realization in the long term, thus making it difficult to quantify their monetary value. This study employs exploratory and qualitative research design by applying inductive and discovery-oriented grounded theory and multiple case research methods. The empirical data comprise interviews with 61 managers from 12 industrial firms, including seven best practice firms in customer value assessment. The findings of this study show that customer value assessment is essentially a crossfunctional process, which involves several organizational functions. The process begins well before and continues long after the actual delivery, often until the end of a supplier´s offering’s life-cycle. Furthermore, the findings shed light on alternative strategies that firms in business markets can adopt to implement the customer value assessment process. Overall, the findings contribute to customer value research, the sales and organizational management literature, the service marketing and solutions business literature, and suggest several managerial implications on how firms in business markets can adopt a holistic approach to assess value created for customers.

Nucleotide excision repair pathway assessment in DNA exposed to low-intensity red and infrared lasers

Low-intensity lasers are used for prevention and management of oral mucositis induced by anticancer therapy, but the effectiveness of treatment depends on the genetic characteristics of affected cells. This study evaluated the survival and induction of filamentation of Escherichia coli cells deficient in the nucleotide excision repair pathway, and the action of T4endonuclease V on plasmid DNA exposed to low-intensity red and near-infrared laser light. Cultures of wild-type (strain AB1157) E. coli and strain AB1886 (deficient in uvrA protein) were exposed to red (660 nm) and infrared (808 nm) lasers at various fluences, powers and emission modes to study bacterial survival and filamentation. Also, plasmid DNA was exposed to laser light to study DNA lesions produced in vitro by T4endonuclease V. Low-intensity lasers:i) had no effect on survival of wild-type E. coli but decreased the survival of uvrA protein-deficient cells,ii) induced bacterial filamentation, iii) did not alter the electrophoretic profile of plasmids in agarose gels, andiv) did not alter the electrophoretic profile of plasmids incubated with T4 endonuclease V. These results increase our understanding of the effects of laser light on cells with various genetic characteristics, such as xeroderma pigmentosum cells deficient in nucleotide excision pathway activity in patients with mucositis treated by low-intensity lasers.