The length of human pregnancy, arguably the most natural of physiological processes, is undergoing subtle but consequential modification in order to adapt to modern societal demands. The gestational age distribution of births in the United States has been shifting to lower gestational ages over the past two decades, parallel to a concomitant rise in obstetrical intervention in pregnancy. The result has been an increase in elective deliveries at 37-38 weeks (early term). A population-based retrospective cohort study of over 616,000 live-born full-term singleton infants was conducted to investigate the association between elective early term delivery and subsequent infant morbidity, mortality, and health care utilization in the first year of life. Data were examined from a statewide, multi-year, clinically-enhanced database created by linking birth certificate records to maternal and infant hospital discharge records, and to infant death certificates, for all infants born to Florida-resident mothers from 2005-09. All infants delivered to mothers with an established medical condition that could have justified early delivery were excluded from the study, as it would not be possible to determine if an early delivery in those cases was elective or medically-necessary. Based on the timing and reason for delivery initiation, the study population was categorized into four exposure groups: 1) early electively induced delivery at 37-38 weeks (EED-I), 2) early elective cesarean delivery at 37-38 weeks (EED-CS), 3) early spontaneous delivery at 37-38 weeks (ESD), 4) early medically-indicated delivery at 37-38 weeks (EID). The comparison group consisted of all expectantly managed infants who were full term deliveries (FTD) at ≥39 weeks. Adverse infant outcomes in the first year of life included respiratory morbidities, neonatal sepsis, feeding difficulties, admission to the neonatal intensive care unit, the frequency and duration of hospital encounters, and infant mortality. Multivariable generalized linear mixed models were used to estimate odds ratios (OR) or rate ratios (RR) and 95% confidence intervals (CI) between exposure and each outcome, adjusting for maternal, infant, and hospital characteristics and accounting for the correlation among infants born at the same facility. Infants who were delivered by EED-I or EED-CS comprised 13% of the study population, and 40% of infants born in the early term period. Infants who were delivered by EED-I experienced the lowest likelihoods of respiratory morbidities, neonatal sepsis, and admission to the NICU when compared to FTD infants. In contrast, infants delivered by EED-CS had significantly increased risks several adverse birth outcomes, with magnitudes ranging from a 9% to 40% increase. Only 8.3% of all infants were re-admitted to the hospital after birth. Despite having the lowest likelihood of the birth morbidities studied, infants delivered by EED-I had a small 10-15% increased odds of being re-hospitalized in the first year of life, compared to FTD infants. These infants also had a slightly higher mean number of visits and combined LOS during post-birth hospitalizations, although the absolute differences from other exposure groups was small. Elective early term cesarean infants actually had a slightly lower risk of re-hospitalization, particularly re-hospitalizations that occurred between weeks 3-52 of life. Neonatal and post-neonatal deaths were rare events (0.3 and 1.3 deaths per 1,000 live births, respectively) in this comparatively low-risk study population. There were no differences in survival when comparing the EED-I and EED-CS groups to the FTD group. The results of this study raise the concern that these public health efforts to reduce elective early term inductions have been based on biased evidence from a limited number of studies in which artificially elevated risks for early electively-induced infants were reported. In stark contrast to the current dogma, this study found that when a methodologically appropriate comparison group was used (i.e., expectant management), elective induction prior to 39 weeks was NOT associated with an increased risk of any adverse infant outcomes in early life. In contrast, our findings do support the avoidance of purely elective cesarean sections prior to 39 weeks in lieu of expectant management. The evidence presented in this large, methodologically-sound study should caution against a general avoidance of ALL elective early term deliveries, and foster support for continued research in this still relatively new arena.

This thesis seeks to evaluate the International Pediatric Emergency Medicine Elective (IPEME) as a case study of a peace-through-health initiative. Using the reasoning of Scolnik (2006), IPEME is first evaluated in terms of narrow, short-term outcomes and subsequently considered in terms of the greater body of peace-through-health work. A novel evaluation tool was designed to examine change in students’ ethical and professional attitudes over the course of the four-week elective. Supplementary qualitative data was collected to shed light on evaluation findings and provide insight into the advantages and disadvantages of the IPEME curriculum. Ethics and professionalism were defined in terms of the WHO 5 Star Global Criteria for Global Doctors conceptualized by the World Health Organization (Boelen, 1996). This research discusses these findings in light of the study’s limitations and considers their implications for IPEME as a medical elective and for its contribution to the greater body of peace-through-health work.

This thesis seeks to evaluate the International Pediatric Emergency Medicine Elective (IPEME) as a case study of a peace-through-health initiative. Using the reasoning of Scolnik (2006), IPEME is first evaluated in terms of narrow, short-term outcomes and subsequently considered in terms of the greater body of peace-through-health work. A novel evaluation tool was designed to examine change in students’ ethical and professional attitudes over the course of the four-week elective. Supplementary qualitative data was collected to shed light on evaluation findings and provide insight into the advantages and disadvantages of the IPEME curriculum. Ethics and professionalism were defined in terms of the WHO 5 Star Global Criteria for Global Doctors conceptualized by the World Health Organization (Boelen, 1996). This research discusses these findings in light of the study’s limitations and considers their implications for IPEME as a medical elective and for its contribution to the greater body of peace-through-health work.

Little is known about how the decision for elective cesarean section comes about in the clinical environment. A prospective longitudinal study based on the Health Belief Model was conducted about first time mothers’ decision making processes and their health beliefs which led to their satisfaction with their decision about their mode of delivery. A convenience sample of 144 nulliparous women with singleton pregnancies and no medical indications requiring a cesarean delivery were recruited using internet based informational notices and with flyers. Women (n = 127) planning a vaginal delivery (VDMR) represented 88.2% of the sample and women (n = 17) requesting a cesarean delivery (CDMR) represented 11.8% of the sample. Data were collected during the third trimester and six weeks after the delivery using an internet-based questionnaire. Data were analyzed using t-tests and multiple linear regression to predict the effect of maternal health beliefs, maternal childbirth self efficacy, partner support, acceptance of the maternal role, and request group (VDMR vs. CDMR) on the dependent variables of maternal perception of the delivery and maternal satisfaction with her decision for the mode of delivery. Compared to women with VDMR, women with CDMR were significantly older, less educated, perceived more risk of emergent cesarean and less ability to deliver vaginally. Hypothesis testing indicated that the overall regression model did not significantly predict maternal perception of the delivery. The model accounted for a significant amount (15.1 %) of the variance in maternal satisfaction with the decision for mode of delivery. Acceptance of the maternal role and maternal request group significantly contributed to the model indicating that women with higher acceptance of the maternal role and women with CDMR had poorer satisfaction with their decision for the mode of delivery. The findings showed that factors influencing maternal perceptions of the delivery and satisfaction with the mode of delivery are different. Health beliefs had less relevance for perception of the delivery. It is possible that experiences that occur within the context of the delivery are more salient for maternal perception. Women with higher acceptance of the maternal role and who request a cesarean delivery are at risk for less satisfaction with their delivery decision and more decisional conflict and thus may need more support during decision-making processes and after delivery. Future research should examine the long-term impact of dissatisfaction with delivery decision on maternal outcomes.

Syfte: Syftet var att beskriva hur sjukvårdspersonal kan hjälpa vuxna patienter att sluta röka, en kortare eller längre tid, inför en elektiv operation.Metod: Studien genomfördes som en litteraturöversikt. Genom sökning i databaserna Pubmed och Cinahl erhölls 10 vetenskapliga artiklar. Sökningar genomfördes med både MeSH-termer och fritextsökning. Artiklarna kvalitetsgranskades, analyserades och samanställdes. Resultat: Metoder som kan användas för att hjälpa patienter att sluta röka är olika former av rådgivning och utbildning: hälsoutbildning, program för livsstilsförändringar, sluta-röka-linje. Att erbjuda rådgivning och stöd i kombination nikotinersättningspreparat är fungerande metoder: motiverande samtal och nikotinersättning, regelbunden rådgivning och nikotinersättning, rökavvänjning med hjälp av interaktivt dataprogram, information och hjälp med planering, nikotinersättning och uppmuntrande telefonsamtal. Effekten av nikotinplåster, läkemedel och akupunktstimulering som ensamma metoder var begränsad. Slutsatser: Olika former av rådgivning eller utbildning kan användas när patienter behöver sluta röka inför en elektiv operation. Metoder som kombinerar nikotinersättning och rådgivning eller stöd var mest effektiva. Använder sig sjukvårdspersonal av detta kan lidande minskas, undvika förlängd vårdtid och pengar sparas.

This study responds to the globally increasing rate of caesarean section, and specifically to the very high rate of elective caesarean section among Taiwanese mothers as evidence suggests that such elective caesareans pose potential health risks for mothers and babies. The purpose of this study was to develop and evaluate a multi-component instrument based on the theory of planned behavior (TPB) to better understand Taiwanese pregnant women's decisions regarding their childbirth delivery options (spontaneous vaginal delivery or elective caesarean section). The study was a four-phased mixed method design. First, the TPB guided item development and instrument drafting. Second, pretesting and instrument refinement used cognitive interviewing with a small sample of Taiwanese pregnant women. Third, the instrument was administered to 310 such women to examine psychometric properties of the component scales. Fourth, the phase 3 instrument was re-administered to 30 women to estimate item stability. Confirmatory factor analyses (CFA) were used to assess construct validity of the multi-item, multi-component measurement model with LISREL 9.1. Based on the TPB, the 52-item self-administered Childbirth Delivery Options Questionnaire (CDOQ) was developed to measure three components: intention regarding delivery options, attitudes toward delivery options, and perceptions of significant others' (partner, mother, and mother-in-law) feelings about delivery options. Respondents from phase two thought that the items on the CDOQ were easy to read and comprehend; they reported favorably on the wording and formatting. Preliminary item analysis revealed that the items referring to dangerousness of delivery options did not function as intended and were dropped because they did not differentiate between the two delivery options, leaving 36 items. Test-retest reliability indicated that responses to each item were positively correlated and those referring to spontaneous vaginal delivery were more stable than those referring to elective caesarean section. Corrected item-to-total correlations and expected change in Cronbach's alpha if item deleted revealed that four items might form a measure of general social norms associated with the Taiwanese culture. The Cronbach's alphas for the components of the CDOQ ranged from .55 to .89. The measurement model incorporating the design features of the CDOQ fitted the data well using the CFA. Because serious problems with multicollinearity and suppression were revealed, Beckstead's (2012) criterion-irrelevant-variance-omitted (CIVO) regression method was used to untangle the suppressor effects when predicting intention from the other components of the CDOQ. The results indicated that attitude and partner's feelings were significant and explained the bulk of the variance in intentions. The TPB-based instrument developed here will be of considerable use to maternal-child health researchers. The findings of this study suggest that decisions regarding delivery options may be modified by interventions geared toward pregnant women's attitudes within family- and cultural-centered prenatal programs.

På ingenjörsutbildningar får studenter fördjupa sina kunskaper i programmets senare del i form av specialinriktningar eller valbara kurser. Detta är något som inte är tillgängligt för studenter som läser till sjöingenjör vid Sjöfartshögskolan i Kalmar men något som infördes på sjöingenjörsutbildningen vid Chalmers Tekniska Högskola 2009. Studiens syfte är att undersöka intresset för valbara kurser på 7,5 högskolepoäng (hp) vardera för sjöingenjörsstudenter vid Sjöfartshögskolan i Kalmar. En enkätstudie svarade på frågorna om vilka ämnesområden som var av intresse, hur många kurser eleven ville läsa, när under utbildningen önskas kursen läsas, om intresset för valbara kurser saknas och i så fall varför. Resultatet av undersökningen visade att de ämnesområden som är av störst intresse för studenterna på grundnivå är offshore/oljerigg och landkurser. På fördjupningsnivå är el- och reglerteknik samt maskinteknik önskvärda. Studien visade att studenterna vill läsa två valbara kurser under utbildningens sista termin. Det går inte att få ett svar på varför studenterna inte vill införa valbara kurser p.g.a. stor spridning av svaren. / In engineering courses, students deepen their knowledge in the later part of the program in form of specializations or elective courses. This is something that is not available to students who study for marine engineer at Kalmar Maritime Academy, a situation that has been present at Chalmers University of Technology since 2009. The purpose of the study is to explore the interest in elective courses of 7.5 credits apiece for marine engineer students at Kalmar Maritime Academy. A questionnaire study was carried out to ascertain as to wheather which topics were of interest, how many courses the student wanted to read, the durability of the course, if interest in the elective course was missing, and if so why. The survey results showed that the subjects of most interest to students at the bachelor level were offshore/oil rig and ashore courses. At the advanced level, electric and control engineering together with mechanical engineering were desirable. The study showed that students want to read two elective courses during the last term. A result cannot be obtained as to why students do not wish to introduce elective courses, this can be attributed to the large spread of responses.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

Esta tese aborda o trabalho de cirurgiões de um hospital de Porto Alegre, RS, durante procedimentos eletivos de pequeno, médio e grande porte, visando o estudo das possíveis relações entre as demandas física e mental e a idade e a experiência do cirurgião. Inicialmente, foi feito um mapeamento de constrangimentos ergonômicos relacionados ao trabalho cirúrgico e, num segundo momento: i) o nível de demanda física imposta aos cirurgiões eletivos por meio de uma técnica de avaliação de posturas (REBA – Rapid Entire Body Assessment) (HIGNETT & McATAMNEY, 2000), da Freqüência Cardíaca (FC), da Pressão Arterial (PA) (sistólica e diastólica) e do nível de hormonal (Noradrenalina) e; ii) o nível de demanda mental envolvida no trabalho por meio do nível hormonal (cortisol, Adenocorticotrófico – ACTH e Adrenalina e, também, por meio da FC e PA). De maneira geral, ficou evidente que, independentemente do tipo de cirurgia, há a presença de carga física de pouca intensidade e de carga mental de média intensidade entre os cirurgiões. Os resultados apontaram, também, que os cirurgiões mais jovens (menos experientes) apresentam mais esforço mental do que físico, principalmente nas cirurgias de grande porte, e os mais experientes têm mais esforço físico nas cirurgias de pequeno porte e menos esforço mental, em comparação aos mais jovens (menos experientes), nas cirurgias de grande porte. / This research has as its main objective to evaluate the relationships between both physical and mental workloads and age and experience related to surgeon’s work. The data collection was conducted at a hospital in Porto Alegre, State of RS, during elective surgeries of low, moderate and high levels of complexity. At first, a survey of ergonomics constraints related to surgical work was carried out. The objected were: i) to investigate the physical demand level by means of posture assessment technique (REBA – Rapid Entire Body Assessment) (HIGNETT & McATAMNEY, 2000), Heart Rate (HR), Blood Pressure (BP) (systolic and dyastolic) and cathecolamines (Noradrenaline); ii) to investigate the mental demand level through assessment of hormonal levels (cortisol, adenocorticotrophic - ACTH and cathecolamines – adrenaline) as well as HR and BP. The results indicated low physical workload and moderate mental workload amongst surgeons. It was found that the workload (physical and mental) was not dependent on the type of surgery performed. Also, the results suggested that the youngest surgeons (novice) have more mental effort than physical effort, mostly in surgeries of high complexity level, as opposed to the oldest surgeons (seniors) who have more physical effort during surgeries in low level of complexity and low mental effort in surgeries in high level of complexity.

Esta tese aborda o trabalho de cirurgiões de um hospital de Porto Alegre, RS, durante procedimentos eletivos de pequeno, médio e grande porte, visando o estudo das possíveis relações entre as demandas física e mental e a idade e a experiência do cirurgião. Inicialmente, foi feito um mapeamento de constrangimentos ergonômicos relacionados ao trabalho cirúrgico e, num segundo momento: i) o nível de demanda física imposta aos cirurgiões eletivos por meio de uma técnica de avaliação de posturas (REBA – Rapid Entire Body Assessment) (HIGNETT & McATAMNEY, 2000), da Freqüência Cardíaca (FC), da Pressão Arterial (PA) (sistólica e diastólica) e do nível de hormonal (Noradrenalina) e; ii) o nível de demanda mental envolvida no trabalho por meio do nível hormonal (cortisol, Adenocorticotrófico – ACTH e Adrenalina e, também, por meio da FC e PA). De maneira geral, ficou evidente que, independentemente do tipo de cirurgia, há a presença de carga física de pouca intensidade e de carga mental de média intensidade entre os cirurgiões. Os resultados apontaram, também, que os cirurgiões mais jovens (menos experientes) apresentam mais esforço mental do que físico, principalmente nas cirurgias de grande porte, e os mais experientes têm mais esforço físico nas cirurgias de pequeno porte e menos esforço mental, em comparação aos mais jovens (menos experientes), nas cirurgias de grande porte. / This research has as its main objective to evaluate the relationships between both physical and mental workloads and age and experience related to surgeon’s work. The data collection was conducted at a hospital in Porto Alegre, State of RS, during elective surgeries of low, moderate and high levels of complexity. At first, a survey of ergonomics constraints related to surgical work was carried out. The objected were: i) to investigate the physical demand level by means of posture assessment technique (REBA – Rapid Entire Body Assessment) (HIGNETT & McATAMNEY, 2000), Heart Rate (HR), Blood Pressure (BP) (systolic and dyastolic) and cathecolamines (Noradrenaline); ii) to investigate the mental demand level through assessment of hormonal levels (cortisol, adenocorticotrophic - ACTH and cathecolamines – adrenaline) as well as HR and BP. The results indicated low physical workload and moderate mental workload amongst surgeons. It was found that the workload (physical and mental) was not dependent on the type of surgery performed. Also, the results suggested that the youngest surgeons (novice) have more mental effort than physical effort, mostly in surgeries of high complexity level, as opposed to the oldest surgeons (seniors) who have more physical effort during surgeries in low level of complexity and low mental effort in surgeries in high level of complexity.