重症加强监护医学与临床思维

重症加强监护医学的发展史,也是其临床思维的发展史,一个由个体性呼吸衰竭救治观念转化为集群性救治启动了重症加强监护学的建立,它们的发展带动亦受益于其临床思维、动态思维的发展。重症加强监护的实施,引发了医学伦理学新的思考与选择,而新的生物技术革命,必将导致重症加强监护医学及其临床思维的巨大变革。     

Who shall be Allowed to Give? Living Organ Donors and the Concept of Autonomy

Free and informed consent is generally acknowledged as the legal andethical basis for living organ donation, but assessments of livingdonors are not always an easy matter. Sometimes it is necessary toinvolve psychosomatics or ethics consultation to evaluate a prospectivedonor to make certain that the requirements for a voluntary andautonomous decision are met. The paper focuses on the conceptualquestions underlying this evaluation process. In order to illustrate howdifferent views of autonomy influence the decision if a donor's offer isethically acceptable, three cases are presented – from Germany, theUnited States, and India. Each case features a person with questionabledecision-making capacity who offered to donate a kidney for a siblingwith severe renal insufficiency. Although the normative framework issimilar in the three countries, different or sometimes even contraryarguments for and against accepting the offer were brought forward. Thesubsequent analysis offers two explanations for the differences inargumentation and outcome in spite of the shared reference to autonomyas the guiding principle: (1) Decisions on the acceptability of a livingdonor cannot simply be deducted from the principle of autonomy but needto integrate contextual information; (2) understandings of the wayautonomy should be contextualized have an important influence on theevaluation of individual cases. Conclusion: Analyzing the conceptualassumptions about autonomy and its relationship to contextual factorscan help in working towards more transparent and better justifieddecisions in the assessment of living organ donors.     

Order of Information Affects Clinical Judgment

Family practice physicians read a case vignette describing a patient with a history of lung cancer, a new transient neurological disturbance, and a normal computerized tomographic (CT) scan of the head. They then estimated the probabilities of two diagnoses: transient ischemic attack (TIA) and brain tumor. Probability estimates of TIA were lower if the history of lung cancer was presented at the end of the case rather than at the beginning. This recency effect was found for both more and less experienced physicians and whether subjects were prompted for a single end-of-sequence probability judgment or multiple step-by-step judgments after each piece of information. These results are inconsistent with Hogarth and Einhorn's (1992) belief-adjustment model, which predicts a recency effect for the step-by-step condition but a primacy effect for the end-of-sequence condition.     

Learning from people, things, and signs

Starting from the observation that small children can count more objects than numbers—a phenomenon that I am calling the “lifeworld dependency of cognition”—and an analysis of finger calculation, the paper shows how learning can be explained as the development of cognitive systems. Parts of those systems are not only an individual’s different forms of knowledge and cognitive abilities, but also other people, things, and signs. The paper argues that cognitive systems are first of all semiotic systems since they are dependent on signs and representations as mediators. The two main questions discussed here are how the external world constrains and promotes the development of cognitive abilities, and how we can move from cognitive abilities that are necessarily connected with concrete situations to abstract knowledge.

The Aggregated Consequences of Motivated Reasoning and the Dynamics of Partisan Presidential Approval

Research in political psychology has shown the importance of motivated reasoning as a prism through which individuals view the political world. From this we develop the hypothesis that, with strong positive beliefs firmly in place, partisan groups ignore or discount information about the performance of political figures they like. We then speculate about how this tendency should manifest itself in presidential approval ratings and test our hypotheses using monthly presidential approval data disaggregated by party identification for the 1955–2005 period. Our results show that partisan groups generally do reward and punish presidents for economic performance, but only those presidents of the opposite party. We also develop a model of presidential approval for self-identified Independents and, finally, a model of the partisan gap , the difference in approval between Democrat and Republican identifiers.     

Reasoning with conditionals

This paper reviews the psychological investigation of reasoning with conditionals, putting an emphasis on recent work. In the first part, a few methodological remarks are presented. In the second part, the main theories of deductive reasoning (mental rules, mental models, and the probabilistic approach) are considered in turn; their content is summarised and the semantics they assume for if and the way they explain formal conditional reasoning are discussed, in particular in the light of experimental work on the probability of conditionals. The last part presents the recent shift of interest towards the study of conditional reasoning in context, that is, with large knowledge bases and uncertain premises.     

进化频率表征对统计推理（非）灵活性的影响：认知风格和简要提示不影响贝叶斯推理

当形式操纵有助于贝叶斯推理时会有怎样的加工发生呢？一种观点认为自然取样的频率可以激发在其操作中具有相对特异性的特权表征系统。而与之相对的一种观点则认为,自然取样频率只是引发具有嵌套关系的更为普遍的加工的一种方式。比较两种观点,后者预示着只需要使用相当简要和直接的干预（如简单的指示）就能够促进推理的改善,而前者则意味着更为广泛的干预和/或更有洞见的理解才能改善推理。本研究表明,无论是短暂立即的干预,还是预存的表征偏向,抑或是表征的灵活性都不能促进被试的表现。另一方面,也有证据显示,频率论者的问题解释可以改善统计推理表现,而且有时还会增加其反应的信心。这些结果支持了特权表征系统观     

Adaptive non-interventional heuristics for covariation detection in causal induction: model comparison and rational analysis

In this article, 41 models of covariation detection from 2 × 2 contingency tables were evaluated against past data in the literature and against data from new experiments. A new model was also included based on a limiting case of the normative phi-coefficient under an extreme rarity assumption, which has been shown to be an important factor in covariation detection (McKenzie & Mikkelsen, 2007) and data selection (Hattori, 2002; Oaksford & Chater, 1994, 2003). The results were supportive of the new model. To investigate its explanatory adequacy, a rational analysis using two computer simulations was conducted. These simulations revealed the environmental conditions and the memory restrictions under which the new model best approximates the normative model of covariation detection in these tasks. They thus demonstrated the adaptive rationality of the new model.     

对心血管病学若干进展的反思

心电起搏的发展经历曲折的过程,反映出以技术和设备为本的缺陷,以人为本可弥补这些缺陷;对介入新技术的过热应用反映了以技术为本的弊端;临床试验证据只反映某种情况下的患者共性,对试验证据的僵化理解和运用违背了循证医学的本义,以人为本可较好地解决这一矛盾;预防为主是以人为本的最好体现,应得到广泛的重视和实施。以人为本是医学的核心价值和出发点。     

吉兰-巴雷综合征的临床循证诊疗策略及思考

介绍吉兰-巴雷综合征（GBs）病因治疗的循证医学证据,主要包括血浆置换、静脉注射免疫球蛋白、糖皮质激素。简述循证医学三大要素：收集最新最好的科学研究依据、熟练的临床经验、就诊病人的特殊情况,阐发GBS的循证医学诊疗决策。阐述循证医学与经验医学的区别,循证医学并不排除科学的经验积累,并从GBS激素的使用对循证医学与专家经验的关系进行哲学思考。