A literatura no Ensino Fundamental - anos iniciais: entre o prazer emancipatório e o escolar pragmático

The Children's Literature is an invaluable tool for human formation, ethics, aesthetics and politics, as well as serves as an instrument for the formation of interdiscourse and transforms teaching procedures of text written production. Then, the investigation of how the literature is being worked in school. Therefore, in this work, constitutes the general objective, to investigate how the teaching of Children's Literature is organized in the early years of elementary school and if that organization promotes the development of literary literacy of the student, and language skills written and the reader behavior, making it critical on several topics. The question that served as a north to the research was the following one: is Teaching Children's Literature, in the early years of elementary school, organized to develop the literary literacy while acting as a catalyst tool for learning to read and write? Have been established the following objectives: a) describe how the teaching of children's literature is organized (teaching routine) in the 1st, 2nd, 3rd, 4th and 5th years of elementary school ; b) identify the literary genres that have worked in each school year, describe how they are worked out, analyze whether this work is related to the teaching of writing and the nature of that relation ship; c) verify if the Children's Literature teaching procedure seeks ways to articulate literary activities with the establishment of the interdiscourse as content for writing the textual production. The methodology that was included was the field research, from a qualitative interpretation approach and it had as direct data source the natural environment in which it was developed the teaching of Children's Literature. The work presents data results analyzed according to the concepts of Aesthetics of Reception (Iser, 1977; Jauss, 1977), and the functions of Literature, according to Candido (2000), Yasuda (2004), among others. From the results were extracted

Motivação e ensino de espanhol na escola pública paulista: dados quantitativos e qualitativos de um estudo de caso

O presente artigo tem como objetivo apresentar e discutir os resultados de parte de uma pesquisa empírica levada a cabo em 2008 com alunos de espanhol de um dos Centros de Estudos de Línguas mantido pelo governo estadual de São Paulo. Tínhamos como meta conhecer e mensurar, até onde fosse possível, o nível de motivação dos alunos em sala de aula, assim como as suas principais causas. Uma vez que tais Centros são, no momento, os responsáveis em São Paulo pela aplicação da lei que torna obrigatória a oferta de língua espanhola nas escolas de nível médio do país (no que se refere à escola pública estadual), consideramos pertinente divulgar tais resultados, de forma que as discussões suscitadas por eles possam contribuir para um ensino de línguas mais motivador e, portanto, mais eficiente. A pesquisa, de cunho quantitativo e qualitativo, contou com 161 alunos informantes. Os principais resultados apontaram que i) os estudantes em geral encontram-se motivados durante as aulas de espanhol; ii) a figura do professor, o esforço depreendido, o conteúdo, a autonomia de escolha do idioma estudado e o prazer que têm em aprender a LE foram as principais causas de motivação apresentadas; iii) a falta de conhecimento sobre aspectos culturais da língua alvo foi apontada como uma das principais causas de desmotivação; iv) as atividades descritas como mais motivadoras foram, pela ordem, jogos e brincadeiras, vídeos/filmes e músicas; v) as atividades consideradas menos motivadoras foram seminário, prova oral/chamada oral e redação.

Creazione e sviluppo di corpora multimediali. Nuove metodologie di ricerca nella traduzione audiovisiva

The construction and use of multimedia corpora has been advocated for a while in the literature as one of the expected future application fields of Corpus Linguistics. This research project represents a pioneering experience aimed at applying a data-driven methodology to the study of the field of AVT, similarly to what has been done in the last few decades in the macro-field of Translation Studies. This research was based on the experience of Forlixt 1, the Forlì Corpus of Screen Translation, developed at the University of Bologna’s Department of Interdisciplinary Studies in Translation, Languages and Culture. As a matter of fact, in order to quantify strategies of linguistic transfer of an AV product, we need to take into consideration not only the linguistic aspect of such a product but all the meaning-making resources deployed in the filmic text. Provided that one major benefit of Forlixt 1 is the combination of audiovisual and textual data, this corpus allows the user to access primary data for scientific investigation, and thus no longer rely on pre-processed material such as traditional annotated transcriptions. Based on this rationale, the first chapter of the thesis sets out to illustrate the state of the art of research in the disciplinary fields involved. The primary objective was to underline the main repercussions on multimedia texts resulting from the interaction of a double support, audio and video, and, accordingly, on procedures, means, and methods adopted in their translation. By drawing on previous research in semiotics and film studies, the relevant codes at work in visual and acoustic channels were outlined. Subsequently, we concentrated on the analysis of the verbal component and on the peculiar characteristics of filmic orality as opposed to spontaneous dialogic production. In the second part, an overview of the main AVT modalities was presented (dubbing, voice-over, interlinguistic and intra-linguistic subtitling, audio-description, etc.) in order to define the different technologies, processes and professional qualifications that this umbrella term presently includes. The second chapter focuses diachronically on various theories’ contribution to the application of Corpus Linguistics’ methods and tools to the field of Translation Studies (i.e. Descriptive Translation Studies, Polysystem Theory). In particular, we discussed how the use of corpora can favourably help reduce the gap existing between qualitative and quantitative approaches. Subsequently, we reviewed the tools traditionally employed by Corpus Linguistics in regard to the construction of traditional “written language” corpora, to assess whether and how they can be adapted to meet the needs of multimedia corpora. In particular, we reviewed existing speech and spoken corpora, as well as multimedia corpora specifically designed to investigate Translation. The third chapter reviews Forlixt 1's main developing steps, from a technical (IT design principles, data query functions) and methodological point of view, by laying down extensive scientific foundations for the annotation methods adopted, which presently encompass categories of pragmatic, sociolinguistic, linguacultural and semiotic nature. Finally, we described the main query tools (free search, guided search, advanced search and combined search) and the main intended uses of the database in a pedagogical perspective. The fourth chapter lists specific compilation criteria retained, as well as statistics of the two sub-corpora, by presenting data broken down by language pair (French-Italian and German-Italian) and genre (cinema’s comedies, television’s soapoperas and crime series). Next, we concentrated on the discussion of the results obtained from the analysis of summary tables reporting the frequency of categories applied to the French-Italian sub-corpus. The detailed observation of the distribution of categories identified in the original and dubbed corpus allowed us to empirically confirm some of the theories put forward in the literature and notably concerning the nature of the filmic text, the dubbing process and Italian dubbed language’s features. This was possible by looking into some of the most problematic aspects, like the rendering of socio-linguistic variation. The corpus equally allowed us to consider so far neglected aspects, such as pragmatic, prosodic, kinetic, facial, and semiotic elements, and their combination. At the end of this first exploration, some specific observations concerning possible macrotranslation trends were made for each type of sub-genre considered (cinematic and TV genre). On the grounds of this first quantitative investigation, the fifth chapter intended to further examine data, by applying ad hoc models of analysis. Given the virtually infinite number of combinations of categories adopted, and of the latter with searchable textual units, three possible qualitative and quantitative methods were designed, each of which was to concentrate on a particular translation dimension of the filmic text. The first one was the cultural dimension, which specifically focused on the rendering of selected cultural references and on the investigation of recurrent translation choices and strategies justified on the basis of the occurrence of specific clusters of categories. The second analysis was conducted on the linguistic dimension by exploring the occurrence of phrasal verbs in the Italian dubbed corpus and by ascertaining the influence on the adoption of related translation strategies of possible semiotic traits, such as gestures and facial expressions. Finally, the main aim of the third study was to verify whether, under which circumstances, and through which modality, graphic and iconic elements were translated into Italian from an original corpus of both German and French films. After having reviewed the main translation techniques at work, an exhaustive account of possible causes for their non-translation was equally provided. By way of conclusion, the discussion of results obtained from the distribution of annotation categories on the French-Italian corpus, as well as the application of specific models of analysis allowed us to underline possible advantages and drawbacks related to the adoption of a corpus-based approach to AVT studies. Even though possible updating and improvement were proposed in order to help solve some of the problems identified, it is argued that the added value of Forlixt 1 lies ultimately in having created a valuable instrument, allowing to carry out empirically-sound contrastive studies that may be usefully replicated on different language pairs and several types of multimedia texts. Furthermore, multimedia corpora can also play a crucial role in L2 and translation teaching, two disciplines in which their use still lacks systematic investigation.

La didattica della traduzione specializzata dallo spagnolo in italiano: competenza traduttiva, genere testuale e nuove tecnologie

Il progetto di ricerca che presentiamo nasce dalla virtuosa combinazione di teoria e prassi didattica nello spirito della ricerca-azione. Scopo del presente lavoro è elaborare un percorso didattico di formazione alla traduzione specializzata in ambito medico-scientifico, tecnico ed economico-giuridico per la combinazione linguistica spagnolo-italiano all’interno della cornice istituzionale concreta dell’università italiana oggi. La nostra proposta formativa si fonda su tre elementi: la ricognizione del mercato attuale della traduzione per la combinazione linguistica indicata, l’individuazione degli obiettivi formativi in base al modello di competenza traduttiva scelto, l’elaborazione del percorso didattico per competenze e basato sull’enfoque por tareas di traduzione. Nella progettazione delle modalità didattiche due sono gli aspetti che definiscono il percorso proposto: il concetto di genere testuale specializzato per la traduzione e la gestione delle informazioni mediante le nuove tecnologie (corpora, banche dati terminologiche e fraseologiche, memorie di traduzione, traduzione controllata). Il presente lavoro si articola in due parti: la prima parte (quattro capitoli) presenta l’inquadramento teorico all’interno del quale si sviluppa la riflessione intorno alla didattica della traduzione specializzata; la seconda parte (due capitoli) presenta l’inquadramento metodologico e analitico all’interno del quale si elabora la nostra proposta didattica. Nel primo capitolo si illustrano i rapporti fra traduzione e mondo professionale; nel secondo capitolo si presenta il concetto di competenza traduttiva come ponte tra la formazione e il mondo della traduzione professionale; nel terzo capitolo si ripercorrono le tappe principali dell’evoluzione della didattica della traduzione generale; nel quarto capitolo illustriamo alcune tra le più recenti e complete proposte didattiche per la traduzione specializzata in ambito tecnico, medico-scientifico ed economico-giuridico. Nel quinto capitolo si introduce il concetto di genere testuale specializzato per la traduzione e nel sesto capitolo si illustra la proposta didattica per la traduzione specializzata dallo spagnolo in italiano che ha motivato il presente lavoro.

Les TICE pour la production écrite et la traduction de l'italien vers le français : le cas de la SSLMIT de Forlì

Les recherches relatives à l'utilisation des TICE se concentrent fréquemment soit sur la dimension cognitive, sur la dimension linguistique ou sur la dimension culturelle. Le plus souvent, les recherches empiriques se proposent d'évaluer les effets directs des TICE sur les performances langagières des apprenants. En outre, les recherches, surtout en psychologie cognitive, sont le plus souvent effectuées en laboratoire. C'est pourquoi le travail présenté dans cette thèse se propose d'inscrire l'utilisation des TICE dans une perspective écologique, et de proposer une approche intégrée pour l'analyse des pratiques effectives aussi bien en didactique des langues qu'en didactique de la traduction. En ce qui concerne les aspects cognitifs, nous recourons à un concept apprécié des praticiens, celui de stratégies d'apprentissage. Les quatre premiers chapitres de la présente thèse sont consacrés à l'élaboration du cadre théorique dans lequel nous inscrivons notre recherche. Nous aborderons en premier lieu les aspects disciplinaires, et notamment l’interdisciplinarité de nos deux champs de référence. Ensuite nous traiterons les stratégies d'apprentissage et les stratégies de traduction. Dans un troisième mouvement, nous nous efforcerons de définir les deux compétences visées par notre recherche : la production écrite et la traduction. Dans un quatrième temps, nous nous intéresserons aux modifications introduites par les TICE dans les pratiques d'enseignement et d'apprentissage de ces deux compétences. Le cinquième chapitre a pour objet la présentation, l'analyse des données recueillies auprès de groupes d'enseignants et d'étudiants de la section de français de la SSLMIT. Il s’agira dans un premier temps, de présenter notre corpus. Ensuite nous procéderons à l’analyse des données. Enfin, nous présenterons, après une synthèse globale, des pistes didactiques et scientifiques à même de prolonger notre travail.

Daniello Bartoli, Il Giappone, Edizione critica

La tesi di ricerca ha portato alla realizzazione di un’edizione critica del Giappone di Daniello Bartoli (1660): per la prima volta la «seconda parte» dell’Asia trova, in questo lavoro, una trascrizione integrale condotta con moderni criteri filologi. Quanto all’esegesi la ricerca ha visto la compilazione di tre «Schedari»: un «Indice dei nomi», che vede l’identificazione dei personaggi storici citati esplicitamente nell’opera, ne traccia un rapido profilo biografico e ne fornisce precisa e aggiornata bibliografia. Per quanto riguarda i missionari evocati dall’autore nel testo, questa sezione indica se (e dove) si tratta di personaggio o di fonte (registrando, nel caso, il luogo o i luoghi in cui Bartoli ricorre a tale testimonianza); un «Indice dei luoghi», che dà l’indicazione moderna del luogo citato e ne fornisce il riscontro con i repertori più aggiornati; un «Lessico» riservato ai termini giapponesi presenti nel testo che vengono spiegati e, là dove possibile, studiati nella loro storia, nella loro presenza nella coeva letteratura di viaggio e corredati di utili riferimenti bibliografici. Le pagine introduttive inquadrano l’opera di Bartoli sia nell’orizzonte biografico dell’autore sia nel milieu gesuitico barocco, fornendo puntuali coordinate storiche grazie alle quali recuperare il più ampio contesto delle missioni gesuitiche nell’Estremo Oriente tra Cinque e Seicento. Particolare attenzione è stata riservata al modo di intendere il compito dello storico da parte di Bartoli: una storiografia la sua che s’intreccia in modi affatto peculiari alle diverse forme stilistiche e dinamiche retoriche richieste dalle altre due grandi attività a cui egli dedicò impegno e passione: l’insegnamento e la predicazione.

Autorenwerkzeuge für digitale, multimediale und interaktive Lernbausteine im Web 2.0

Die Forschungsarbeit siedelt sich im Dreieck der Erziehungswissenschaften, der Informatik und der Schulpraxis an und besitzt somit einen starken interdisziplinären Charakter. Aus Sicht der Erziehungswissenschaften handelt es sich um ein Forschungsprojekt aus den Bereichen E-Learning und Multimedia Learning und der Fragestellung nach geeigneten Informatiksystemen für die Herstellung und den Austausch von digitalen, multimedialen und interaktiven Lernbausteinen. Dazu wurden zunächst methodisch-didaktische Vorteile digitaler Lerninhalte gegenüber klassischen Medien wie Buch und Papier zusammengetragen und mögliche Potentiale im Zusammenhang mit neuen Web2.0-Technologien aufgezeigt. Darauf aufbauend wurde für existierende Autorenwerkzeuge zur Herstellung digitaler Lernbausteine und bestehende Austauschplattformen analysiert, inwieweit diese bereits Web 2.0-Technologien unterstützen und nutzen. Aus Sicht der Informatik ergab sich aus der Analyse bestehender Systeme ein Anforderungsprofil für ein neues Autorenwerkzeug und eine neue Austauschplattform für digitale Lernbausteine. Das neue System wurde nach dem Ansatz des Design Science Research in einem iterativen Entwicklungsprozess in Form der Webapplikation LearningApps.org realisiert und stetig mit Lehrpersonen aus der Schulpraxis evaluiert. Bei der Entwicklung kamen aktuelle Web-Technologien zur Anwendung. Das Ergebnis der Forschungsarbeit ist ein produktives Informatiksystem, welches bereits von tausenden Nutzern in verschiedenen Ländern sowohl in Schulen als auch in der Wirtschaft eingesetzt wird. In einer empirischen Studie konnte das mit der Systementwicklung angestrebte Ziel, die Herstellung und den Austausch von digitalen Lernbausteinen zu vereinfachen, bestätigt werden. Aus Sicht der Schulpraxis liefert LearningApps.org einen Beitrag zur Methodenvielfalt und zur Nutzung von ICT im Unterricht. Die Ausrichtung des Werkzeugs auf mobile Endgeräte und 1:1-Computing entspricht dem allgemeinen Trend im Bildungswesen. Durch die Verknüpfung des Werkzeugs mit aktuellen Software Entwicklungen zur Herstellung von digitalen Schulbüchern werden auch Lehrmittelverlage als Zielgruppe angesprochen.

A Simple Visual Demonstration of Phase Diagram Concepts for an Introductory Materials Science Course Using Colored Solvents

A simple and effective demonstration to help students comprehend phase diagrams and understand phase equilibria and transformations is created using common chemical solvents available in the laboratory. Common misconceptions surrounding phase diagram operations, such as components versus phases, reversibility of phase transformations, and the lever rule are addressed. Three different binary liquid mixtures of varying compatibility create contrastive phase equilibrium cases, where colorful dyes selectively dissolved in each of corresponding phases allow for quick and unambiguous perceptions of solubility limit and phase transformations. Direct feedback and test scores from a group of students show evidence of the effectiveness of the visual and active teaching tool.

Career Influences of Music Education Audition Candidates

In this descriptive study, we examined the influences and experiences motivating students to enter college-level music schools as reported by a population of precollegiate students auditioning (but not yet accepted) to music education degree programs. As a follow-up to a published pilot study, this research was designed to quantify the various experiences respondents had as part of their precollege school and community programs that related to teaching and music. Results indicate a strong connection between respondents’ primary musical background and future teaching interest. The top three influential experiences were related to high school ensemble membership (band, choir, orchestra), and the most influential group of individuals in the decision to become a music educator were high school ensemble directors. Respondents from all four primary background groups (band, choir, orchestra, and general or other) rated private lesson teaching as their second strongest future teaching interest, just behind teaching at the high school level in their primary background. Respondents rated parents as moderately influential on their desire to become a music teacher.

Effects of instructional changes on student learning of electrochemistry in an IB chemistry course

This study investigated the effectiveness of incorporating several new instructional strategies into an International Baccalaureate (IB) chemistry course in terms of how they supported high school seniors’ understanding of electrochemistry. The three new methods used were (a) providing opportunities for visualization of particle movement by student manipulation of physical models and interactive computer simulations, (b) explicitly addressing common misconceptions identified in the literature, and (c) teaching an algorithmic, step-wise approach for determining the products of an aqueous solution electrolysis. Changes in student understanding were assessed through test scores on both internally and externally administered exams over a two-year period. It was found that visualization practice and explicit misconception instruction improved student understanding, but the effect was more apparent in the short-term. The data suggested that instruction time spent on algorithm practice was insufficient to cause significant test score improvement. There was, however, a substantial increase in the percentage of the experimental group students who chose to answer an optional electrochemistry-related external exam question, indicating an increase in student confidence. Implications for future instruction are discussed.

Autorenwerkzeuge für digitale, multimediale und interaktive Lernbausteine im Web 2.0

Die vorliegende Forschungsarbeit siedelt sich im Dreieck der Erziehungswissenschaften, der Informatik und der Schulpraxis an und besitzt somit einen starken interdisziplinären Charakter. Aus Sicht der Erziehungswissenschaften handelt es sich um ein Forschungsprojekt aus den Bereichen E-Learning und Multimedia Learning und der Fragestellung nach geeigneten Informatiksystemen für die Herstellung und den Austausch von digitalen, multimedialen und interaktiven Lernbausteinen. Dazu wurden zunächst methodisch-didaktische Vorteile digitaler Lerninhalte gegenüber klassischen Medien wie Buch und Papier zusammengetragen und mögliche Potentiale im Zusammenhang mit neuen Web 2.0-Technologien aufgezeigt. Darauf aufbauend wurde für existierende Autorenwerkzeuge zur Herstellung digitaler Lernbausteine und bestehende Austauschplattformen analysiert, inwieweit diese bereits Web 2.0-Technologien unterstützen und nutzen. Aus Sicht der Informatik ergab sich aus der Analyse bestehender Systeme ein Anforderungsprofil für ein neues Autorenwerkzeug und eine neue Austauschplattform für digitale Lernbausteine. Das neue System wurde nach dem Ansatz des Design Science Research in einem iterativen Entwicklungsprozess in Form der Webapplikation LearningApps.org realisiert und stetig mit Lehrpersonen aus der Schulpraxis evaluiert. Bei der Entwicklung kamen aktuelle Web-Technologien zur Anwendung. Das Ergebnis der Forschungsarbeit ist ein produktives Informatiksystem, welches bereits von tausenden Nutzern in verschiedenen Ländern sowohl in Schulen als auch in der Wirtschaft eingesetzt wird. In einer empirischen Studie konnte das mit der Systementwicklung angestrebte Ziel, die Herstellung und den Austausch von digitalen Lernbausteinen zu vereinfachen, bestätigt werden. Aus Sicht der Schulpraxis liefert LearningApps.org einen Beitrag zur Methodenvielfalt und zur Nutzung von ICT im Unterricht. Die Ausrichtung des Werkzeugs auf mobile Endgeräte und 1:1-Computing entspricht dem allgemeinen Trend im Bildungswesen. Durch die Verknüpfung des Werkzeugs mit aktuellen Software-Entwicklungen zur Herstellung von digitalen Schulbüchern werden auch Lehrmittelverlage als Zielgruppe angesprochen.

Online Distance Education: Towards a Research Agenda

Online Distance Education: Towards a Research Agenda offers a systematic overview of the major issues, trends, and areas of priority in online distance education research. In each chapter, an international expert or team of experts provides an overview of one timely issue in online distance education, summarizing major research on the topic, discussing theoretical insights that guide the research, posing questions and directions for future research, and discussing the implications for distance education practice as a whole. Intended as a primary reference and guide for distance educators, researchers, and policymakers, Online Distance Education addresses aspects of distance education practice that have often been marginalized, including issues of cost and economics, concerns surrounding social justice, cultural bias, the need for faculty professional development, and the management and growth of learner communities. At once soundly empirical and thoughtfully reflective, yet also forward-looking and open to new approaches to online and distance teaching, this text is a solid resource for researchers in a rapidly expanding discipline.

Plattform Musikalische Bildung

Bei der Plattform Musikalische Bildung handelt es sich um ein Projekt der Hochschule für Musik Detmold. Die Plattform vereinigt in sich Ideen zum vernetzten Musiklernen, neu entwickelten Online-Musiklern-Tools sowie den Austausch und die Modifizierung dieser erstellten Kurse durch andere Dozenten und Lehrenden. Die Plattform steht allen Dozenten und Lehrern, Studierenden und Schülern an Hochschulen, aber auch Musikschulen und allgemein bildenden Schulen kostenlos zur Verfügung. Auf die Einblendung von Werbebannern wird verzichtet. Die Inbetriebnahme einer Betaversion ist im Oktober 2014 erfolgt. Weitere Ausbaustufen sind in Planung aber noch nicht gegenfinanziert.

Detection of haemorrhagic shock: Are vital signs obsolete? A commentary by Dr M. Luginbühl

The ATLS program by the American college of surgeons is probably the most important globally active training organization dedicated to improve trauma management. Detection of acute haemorrhagic shock belongs to the key issues in clinical practice and thus also in medical teaching. (In this issue of the journal William Schulz and Ian McConachrie critically review the ATLS shock classification Table 1), which has been criticized after several attempts of validation have failed [1]. The main problem is that distinct ranges of heart rate are related to ranges of uncompensated blood loss and that the heart rate decrease observed in severe haemorrhagic shock is ignored [2]. Table 1. Estimated blood loos based on patient's initial presentation (ATLS Students Course Manual, 9th Edition, American College of Surgeons 2012). Class I Class II Class III Class IV Blood loss ml Up to 750 750–1500 1500–2000 >2000 Blood loss (% blood volume) Up to 15% 15–30% 30–40% >40% Pulse rate (BPM) <100 100–120 120–140 >140 Systolic blood pressure Normal Normal Decreased Decreased Pulse pressure Normal or ↑ Decreased Decreased Decreased Respiratory rate 14–20 20–30 30–40 >35 Urine output (ml/h) >30 20–30 5–15 negligible CNS/mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic Initial fluid replacement Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood Table options In a retrospective evaluation of the Trauma Audit and Research Network (TARN) database blood loss was estimated according to the injuries in nearly 165,000 adult trauma patients and each patient was allocated to one of the four ATLS shock classes [3]. Although heart rate increased and systolic blood pressure decreased from class I to class IV, respiratory rate and GCS were similar. The median heart rate in class IV patients was substantially lower than the value of 140 min−1 postulated by ATLS. Moreover deterioration of the different parameters does not necessarily go parallel as suggested in the ATLS shock classification [4] and [5]. In all these studies injury severity score (ISS) and mortality increased with in increasing shock class [3] and with increasing heart rate and decreasing blood pressure [4] and [5]. This supports the general concept that the higher heart rate and the lower blood pressure, the sicker is the patient. A prospective study attempted to validate a shock classification derived from the ATLS shock classes [6]. The authors used a combination of heart rate, blood pressure, clinically estimated blood loss and response to fluid resuscitation to classify trauma patients (Table 2) [6]. In their initial assessment of 715 predominantly blunt trauma patients 78% were classified as normal (Class 0), 14% as Class I, 6% as Class II and only 1% as Class III and Class IV respectively. This corresponds to the results from the previous retrospective studies [4] and [5]. The main endpoint used in the prospective study was therefore presence or absence of significant haemorrhage, defined as chest tube drainage >500 ml, evidence of >500 ml of blood loss in peritoneum, retroperitoneum or pelvic cavity on CT scan or requirement of any blood transfusion >2000 ml of crystalloid. Because of the low prevalence of class II or higher grades statistical evaluation was limited to a comparison between Class 0 and Class I–IV combined. As in the retrospective studies, Lawton did not find a statistical difference of heart rate and blood pressure among the five groups either, although there was a tendency to a higher heart rate in Class II patients. Apparently classification during primary survey did not rely on vital signs but considered the rather soft criterion of “clinical estimation of blood loss” and requirement of fluid substitution. This suggests that allocation of an individual patient to a shock classification was probably more an intuitive decision than an objective calculation the shock classification. Nevertheless it was a significant predictor of ISS [6]. Table 2. Shock grade categories in prospective validation study (Lawton, 2014) [6]. Normal No haemorrhage Class I Mild Class II Moderate Class III Severe Class IV Moribund Vitals Normal Normal HR > 100 with SBP >90 mmHg SBP < 90 mmHg SBP < 90 mmHg or imminent arrest Response to fluid bolus (1000 ml) NA Yes, no further fluid required Yes, no further fluid required Requires repeated fluid boluses Declining SBP despite fluid boluses Estimated blood loss (ml) None Up to 750 750–1500 1500–2000 >2000 Table options What does this mean for clinical practice and medical teaching? All these studies illustrate the difficulty to validate a useful and accepted physiologic general concept of the response of the organism to fluid loss: Decrease of cardiac output, increase of heart rate, decrease of pulse pressure occurring first and hypotension and bradycardia occurring only later. Increasing heart rate, increasing diastolic blood pressure or decreasing systolic blood pressure should make any clinician consider hypovolaemia first, because it is treatable and deterioration of the patient is preventable. This is true for the patient on the ward, the sedated patient in the intensive care unit or the anesthetized patients in the OR. We will therefore continue to teach this typical pattern but will continue to mention the exceptions and pitfalls on a second stage. The shock classification of ATLS is primarily used to illustrate the typical pattern of acute haemorrhagic shock (tachycardia and hypotension) as opposed to the Cushing reflex (bradycardia and hypertension) in severe head injury and intracranial hypertension or to the neurogenic shock in acute tetraplegia or high paraplegia (relative bradycardia and hypotension). Schulz and McConachrie nicely summarize the various confounders and exceptions from the general pattern and explain why in clinical reality patients often do not present with the “typical” pictures of our textbooks [1]. ATLS refers to the pitfalls in the signs of acute haemorrhage as well: Advanced age, athletes, pregnancy, medications and pace makers and explicitly state that individual subjects may not follow the general pattern. Obviously the ATLS shock classification which is the basis for a number of questions in the written test of the ATLS students course and which has been used for decades probably needs modification and cannot be literally applied in clinical practice. The European Trauma Course, another important Trauma training program uses the same parameters to estimate blood loss together with clinical exam and laboratory findings (e.g. base deficit and lactate) but does not use a shock classification related to absolute values. In conclusion the typical physiologic response to haemorrhage as illustrated by the ATLS shock classes remains an important issue in clinical practice and in teaching. The estimation of the severity haemorrhage in the initial assessment trauma patients is (and was never) solely based on vital signs only but includes the pattern of injuries, the requirement of fluid substitution and potential confounders. Vital signs are not obsolete especially in the course of treatment but must be interpreted in view of the clinical context. Conflict of interest None declared. Member of Swiss national ATLS core faculty.

Differences in performance for quality of care indicators for acute myocardial infarction (AMI) across various hospital categories in Texas

The study analyzed Hospital Compare data for Medicare Fee-for-service patients at least 65 years of age to determine whether hospital performance for AMI outcome and processes of care measures differ amongst Texas hospitals with respect to ownership status (for profit vs. not-for-profit), academic status (teaching vs. non-teaching) and geographical setting (rural vs. urban). ^ The study found a statistically significant difference between for-profit and not-for-profit hospitals in four process-of-care measures (aspirin at discharge, P=0.028; ACE or ARB inhibitor for LSVD, P=0.048; Smoking cessation advice: P=0.034; outpatients who got aspirin with 24 hours of arrival in the ED, P=0.044). No significant difference in performance was found between COTH-member teaching and non-teaching hospitals for any of the eight process-of-care measures or the two outcome measures for AMI. The study was unable to compare performance based on geographic setting of hospitals due to lack of sufficient data for rural hospitals. ^ The results of the study suggest that for-profit Texas hospitals might be slightly better than not-for –profit hospitals at providing possible heart attack patients with certain processes of care.^