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.

Digital evidence, 'absence' of data and ambiguous patterns of reasoning

In this paper we discuss the use of digital data by the Swiss Federal Criminal Court in a recent case of attempted homicide. We use this case to examine drawbacks for the defense when the presentation of scientific evidence is partial, especially when the only perspective mentioned is that of the prosecution. We tackle this discussion at two distinct levels. First, we pursue an essentially non-technical presentation of the topic by drawing parallels between the court's summing up of the case and flawed patterns of reasoning commonly seen in other forensic disciplines, such as DNA and particle traces (e.g., gunshot residues). Then, we propose a formal analysis of the case, using elements of probability and graphical probability models, to justify our main claim that the partial presentation of digital evidence poses a risk to the administration of justice in that it keeps vital information from the defense. We will argue that such practice constitutes a violation of general principles of forensic interpretation as established by forensic science literature and current recommendations by forensic science interest groups (e.g., the European Network of Forensic Science Institutes). Finally, we posit that argument construction and analysis using formal methods can help replace digital evidence appropriately into context and thus support a sound evaluation of the evidence.

A Case-based reasoning approach to validate grammatical gender and number agreement in Spanish language

Across Latin America 420 indigenous languages are spoken. Spanish is considered a second language in indigenous communities and is progressively introduced in education. However, most of the tools to support teaching processes of a second language have been developed for the most common languages such as English, French, German, Italian, etc. As a result, only a small amount of learning objects and authoring tools have been developed for indigenous people considering the specific needs of their population. This paper introduces Multilingual–Tiny as a web authoring tool to support the virtual experience of indigenous students and teachers when they are creating learning objects in indigenous languages or in Spanish language, in particular, when they have to deal with the grammatical structures of Spanish. Multilingual–Tiny has a module based on the Case-based Reasoning technique to provide recommendations in real time when teachers and students write texts in Spanish. An experiment was performed in order to compare some local similarity functions to retrieve cases from the case library taking into account the grammatical structures. As a result we found the similarity function with the best performance

Clinical reasoning of medical students in a public university in Brazil

The aim of this research was to understand the reasoning developed by medical students in a public university in Brazil. This research on education included semi-structured interviews and film recordings of interns discussing 10 clinical cases. A sample of 16 interns analyzed cases presented on a notebook computer with a webcam. They were instructed to verbalize all their thoughts on the procedures they would use. The film recordings and transcripts of the interviews were analyzed. Quantitative data was evaluated using Yates' chi-squared test and speech analysis was used to evaluate the transcripts. The theme worked on in the practice of reasoning was: the student's perceptions of their clinical practice. Of the 160 diagnoses, 57% were done with analytical reasoning and 43% with non-analytical reasoning. The hypothetical deductive method was employed by 31% of the interns and the inductive method was employed by 69%. The diagnostic accuracy was 81% correct for easy cases and 85% correct for difficult cases. We observed two empirical categories: the cognitive universe of the student and the patient's context.

Determination of slurry’s viscosity using case based reasoning approach

Case-based reasoning (CBR) is a recent approach to problem solving and learning that has got a lot of attention over the last years. In this work, the CBR methodology is used to reduce the time and amount of resources spent on carry out experiments to determine the viscosity of the new slurry. The aim of this work is: to develop a CBR system to support the decision making process about the type of slurries behavior, to collect a sufficient volume of qualitative data for case base, and to calculate the viscosity of the Newtonian slurries. Firstly in this paper, the literature review about the types of fluid flow, Newtonian and non-Newtonian slurries is presented. Some physical properties of the suspensions are also considered. The second part of the literature review provides an overview of the case-based reasoning field. Different models and stages of CBR cycles, benefits and disadvantages of this methodology are considered subsequently. Brief review of the CBS tools is also given in this work. Finally, some results of work and opportunities for system modernization are presented. To develop a decision support system for slurry viscosity determination, software application MS Office Excel was used. Designed system consists of three parts: workspace, the case base, and section for calculating the viscosity of Newtonian slurries. First and second sections are supposed to work with Newtonian and Bingham fluids. In the last section, apparent viscosity can be calculated for Newtonian slurries.

(Arrêt du Grand Conseil qui ordonne la suppression d'un libelle intitulé : "Mémoire pour Messire Gui-Michel Billard de Lorière, conseiller au Grand Conseil, contre dame Marie-Henriette de Saint-Simon, son épouse.)

[Acte. 1755-08-30. Paris]

勑修百丈清規Chi xiu bai zhang qing gui.Rituel et règlements officiels des bonzes.

Par Bai zhang (époque des Tang) ; revu par De hui, et Da su (époque des Yuan). Nouvelle édition (1442) précédée d'un rapport de Hu Yong, ministre des Rites, et de diverses pièces de 1335, 1336, etc.

繡像白圭全傳Xiu xiang bai gui quan zhuan.Histoire illustrée de la tablette blanche.

Par Cui Xiang chuan, de Bai ling ; le titre porte l'indication : édition du 10e romancier de génie par Ji Xiao lan. Ce dernier, postnom Yun, originaire de Xian, a vécu de 1724 à 1805. Préface de Qing chuan ju shi. Portraits des personnages. Édition de la salle Yong an.Livre préliminaire + 4 sections (16 hui).

沈微垣先生規正圖註王叔和難經脉訣大全Shen wei yuan xian sheng gui zheng tu zhu wang shu he nan jing mo jue da quan.Le Mo jue et le Nan jing, édition collective.

Contient : I刪註脈訣規正Shan zhu mo jue gui zheng.Le Mo jue corrigé ; II圖註八十一難經Tu zhu ba shi yi nan jing.Le Nan jing illustré, en 81 sections

丹桂籍Dan gui ji.Collection de traités taoïstes.

Contient : I太上感應篇Tai shang gan ying pian.Le Tai shang gan ying pian ; II文昌帝君陰騭文Wen chang di jun yin zhi wen.Traité de la fixation mystérieuse, par le dieu de la Littérature ; III關夫子覺世眞經Guan fu zi jue shi zhen jing.Le livre sacré de l'éveil du monde, de Guan fu zi ; IV關聖帝君降筆眞經Guan sheng di jun jiang bi zhen jing.Livre sacré écrit par le dieu de la Guerre ; V關聖帝君顯應戒士文Guan sheng di jun xian ying jie shi wen.Conseils aux lettrés, traité par le dieu de la Guerre ; VI東嶽聖帝垂訓Dong yue sheng di chui xun.Instructions du dieu du Dong yue ; VII呂純陽祖師勸世戒食牛犬Lü chun yang zu shi quan shi jie shi niu quan.Défense de manger le bœuf et le chien, traité par Lü Chun yang ; VIII文昌孝經Wen chang xiao jing.Livre sacré de la piété filiale, par Wen chang ; IX蕉窓十則Jiao chuang shi ze.Les dix commandements de Jiao tchhoang ; X功過格纂要Gong ge ge zuan yao.Éléments des règles du mérite et du péché ; XI桂香殿功過格Gui xiang dian gong ge ge.Règles du mérite et du péché, de la salle Gui xiang ; XII靈驗記Ling yan ji.Exemples miraculeux ; XIII文昌帝君降乩惜字功罪例Wen chang di jun jiang ji xi zi gong zui li.Règlement du mérite et du péché, relativement au respect des caractères d'écriture ; donné par le dieu de la Littérature ; XIV, livre préliminaire募刊疏引Mu kan su yin.Rapport et introduction sur la gravure de l'ouvrage ; XV, livre préliminaire婁東善書目錄.Lou dong shan shu mu lu.Liste d'ouvrages recommandés, dressée à Lou dong ; XVI, livre préliminaire文昌帝君丹桂籍靈驗記 。續記.Wen chang di jun dan gui ji ling yan ji. Xu ji.Notice des miracles dus au Dan gui ji du dieu delà Littérature, partie principale et suite ; XVII, livre préliminaire顏廷表先生傳.Yan ting biao xian sheng zhuan.Vie de Yan Ting biao ; XVIII, livre préliminaire顏雲麓先生傳.Yan yun lu xian sheng zhuan.Vie de Yan Yun lu ; XIX, livre préliminaire丹桂籍奉行心法.Dan gui ji feng xing xin fa.Préceptes pour pratiquer les règles du Dan gui ji ; XX, livre préliminaire文昌帝君降筆記.Wen chang di jun jiang bi ji.Notice dictée parle dieu de la Littérature ; XXI, livre préliminaire玉皇寶號.Yu huang bao hao.Les noms précieux de Yu huang ; XXII, livres 1-4九天開化主宰元皇司錄宏仁文昌帝君陰隲文註案Jiu tian kai hua zhu zai yuan huang si lu hong ren wen chang di jun yin zhi wen zhu an.Traité de la fixation mystérieuse, par le dieu de la Littérature ; avec commentaires et exemples ; XXIII, livre final文昌帝君救刧寶章Wen chang di jun jiu jie bao zhang.Précieux articles du dieu de la Littérature pour le salut du monde ; XXIV, livre final梓潼帝君降筆戒士子文Zi tong di jun jiang bi jie shi zi wen.Conseils aux lettrés, deux traités par le dieu de la Littérature ; XXV, livre final文昌帝君勸孝文Wen chang di jun quan xiao wen.Traité pour conseiller la piété filiale, par le dieu de la Littérature ; XXVI, livre final玉中書勸孝歌Yu zhong shu quan xiao ge.Chanson pour conseiller la piété filiale ; XXVII, livre final圓明鬥母天尊勸世文.Yuan ming dou mu tian zun quan shi wen.Conseils au monde, traité de la déesse Yuan ming dou mu ; XXVIII, livre final俞淨意先生遇竈神記.Yu jing yi xian sheng yu zao shen ji.Entrevue de Yu Jing yi avec l'esprit du Foyer ; XXIX, livre final袁了凡先生四訓 。立命之學.Yuan liao fan xian sheng si xun. Li ming zhi xue.Quatre exhortations de Yuan Liao fan. Première section : Science de la direction de la vie ; XXX, livre final積善之方Ji shan zhi fang.Deuxième section : Recette pour accumuler les bonnes actions ; XXXI, livre final改過之法Gai ge zhi fa.Troisième section : Moyen de corriger les fautes ; XXXII, livre final謙德之效Qian le zhi xiao.Quatrième section : Manifestation d'humilité ; XXXIII, livre final佛母準提神咒Fo mu zhun ti shen zhou.Invocation de la mère du Bouddha ; XXXIV, livre final袁了凡先生勸喪文Yuan liao fan xian sheng quan sang wen.Traité de Yuan Liao fan sur les funérailles ; XXXV, livre final遏淫說E yin shuo.Traité contre l'impureté ; XXXVI, livre final行不費錢功德例Xing bu fei qian gong de li.Manière d'obtenir des mérites sans dépenser d'argent

丹桂籍Dan gui ji.Collection de traités taoïstes.

Contient : I太上感應篇Tai shang gan ying pian.Le Tai shang gan ying pian ; II文昌帝君陰騭文Wen chang di jun yin zhi wen.Traité de la fixation mystérieuse, par le dieu de la Littérature ; III關夫子覺世眞經Guan fu zi jue shi zhen jing.Le livre sacré de l'éveil du monde, de Guan fu zi ; IV關聖帝君降筆眞經Guan sheng di jun jiang bi zhen jing.Livre sacré écrit par le dieu de la Guerre ; V關聖帝君顯應戒士文Guan sheng di jun xian ying jie shi wen.Conseils aux lettrés, traité par le dieu de la Guerre ; VI東嶽聖帝垂訓Dong yue sheng di chui xun.Instructions du dieu du Dong yue ; VII呂純陽祖師勸世戒食牛犬Lü chun yang zu shi quan shi jie shi niu quan.Défense de manger le bœuf et le chien, traité par Lü Chun yang ; VIII文昌孝經Wen chang xiao jing.Livre sacré de la piété filiale, par Wen chang ; IX蕉窓十則Jiao chuang shi ze.Les dix commandements de Jiao tchhoang ; X功過格纂要Gong ge ge zuan yao.Éléments des règles du mérite et du péché ; XI桂香殿功過格Gui xiang dian gong ge ge.Règles du mérite et du péché, de la salle Gui xiang ; XII靈驗記Ling yan ji.Exemples miraculeux ; XIII文昌帝君降乩惜字功罪例Wen chang di jun jiang ji xi zi gong zui li.Règlement du mérite et du péché, relativement au respect des caractères d'écriture ; donné par le dieu de la Littérature ; XIV, livre préliminaire募刊疏引Mu kan su yin.Rapport et introduction sur la gravure de l'ouvrage ; XV, livre préliminaire婁東善書目錄.Lou dong shan shu mu lu.Liste d'ouvrages recommandés, dressée à Lou dong ; XVI, livre préliminaire文昌帝君丹桂籍靈驗記 。續記.Wen chang di jun dan gui ji ling yan ji. Xu ji.Notice des miracles dus au Dan gui ji du dieu delà Littérature, partie principale et suite ; XVII, livre préliminaire顏廷表先生傳.Yan ting biao xian sheng zhuan.Vie de Yan Ting biao ; XVIII, livre préliminaire顏雲麓先生傳.Yan yun lu xian sheng zhuan.Vie de Yan Yun lu ; XIX, livre préliminaire丹桂籍奉行心法.Dan gui ji feng xing xin fa.Préceptes pour pratiquer les règles du Dan gui ji ; XX, livre préliminaire文昌帝君降筆記.Wen chang di jun jiang bi ji.Notice dictée parle dieu de la Littérature ; XXI, livre préliminaire玉皇寶號.Yu huang bao hao.Les noms précieux de Yu huang ; XXII, livres 1-4九天開化主宰元皇司錄宏仁文昌帝君陰隲文註案Jiu tian kai hua zhu zai yuan huang si lu hong ren wen chang di jun yin zhi wen zhu an.Traité de la fixation mystérieuse, par le dieu de la Littérature ; avec commentaires et exemples ; XXIII, livre final文昌帝君救刧寶章Wen chang di jun jiu jie bao zhang.Précieux articles du dieu de la Littérature pour le salut du monde ; XXIV, livre final梓潼帝君降筆戒士子文Zi tong di jun jiang bi jie shi zi wen.Conseils aux lettrés, deux traités par le dieu de la Littérature ; XXV, livre final文昌帝君勸孝文Wen chang di jun quan xiao wen.Traité pour conseiller la piété filiale, par le dieu de la Littérature ; XXVI, livre final玉中書勸孝歌Yu zhong shu quan xiao ge.Chanson pour conseiller la piété filiale ; XXVII, livre final圓明鬥母天尊勸世文.Yuan ming dou mu tian zun quan shi wen.Conseils au monde, traité de la déesse Yuan ming dou mu ; XXVIII, livre final俞淨意先生遇竈神記.Yu jing yi xian sheng yu zao shen ji.Entrevue de Yu Jing yi avec l'esprit du Foyer ; XXIX, livre final袁了凡先生四訓 。立命之學.Yuan liao fan xian sheng si xun. Li ming zhi xue.Quatre exhortations de Yuan Liao fan. Première section : Science de la direction de la vie ; XXX, livre final積善之方Ji shan zhi fang.Deuxième section : Recette pour accumuler les bonnes actions ; XXXI, livre final改過之法Gai ge zhi fa.Troisième section : Moyen de corriger les fautes ; XXXII, livre final謙德之效Qian le zhi xiao.Quatrième section : Manifestation d'humilité ; XXXIII, livre final佛母準提神咒Fo mu zhun ti shen zhou.Invocation de la mère du Bouddha ; XXXIV, livre final袁了凡先生勸喪文Yuan liao fan xian sheng quan sang wen.Traité de Yuan Liao fan sur les funérailles ; XXXV, livre final遏淫說E yin shuo.Traité contre l'impureté ; XXXVI, livre final行不費錢功德例Xing bu fei qian gong de li.Manière d'obtenir des mérites sans dépenser d'argent