A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Objective The goal of this study was to investigate the effect of using a two attending surgeon approach on operative time, anesthesia time, and estimated blood loss in patients with neuromuscular scoliosis undergoing posterior spinal fusion surgery. Methods This was a retrospective chart review study of patients with neuromuscular scoliosis who underwent posterior spinal fusion surgery at Phoenix Children’s Hospital in 2011 and 2012. Results Results from 70 patients showed a significant reduction in operative and anesthesia times for patients with two attending surgeons as opposed to one. Mean operative time for the two surgeon group was 3 hours 30 minutes (SD = 49 minutes) and was significantly shorter than 4 hours 26 minutes (SD = 1 hour 22 minutes), the mean operative time for the one surgeon group, t (56) =3.44, p = .001. Mean anesthesia time for the two surgeon group was 5 hours 28 minutes (SD = 55 minutes) and was significantly shorter than 6 hours 9 minutes (SD = 1 hour 28 minutes), the mean anesthesia time for the one surgeon group, t (57) = -2.34, p = .023. There was no significant difference in estimated blood loss found between the groups. The mean blood loss for the two surgeon group was 1202.1 ml( SD = 1033.1) versus 1042.1 ml (SD = 959.41) for the one surgeon group, t(68) = .671, p = .50. This pattern of results remained the same in subgroup analysis designed to compare cases with similar severity of presentation. Significance Patients with neuromuscular scoliosis may benefit from a two attending surgeon approach to posterior spinal fusion. More studies are needed to determine modifiable risk factors for excessive blood loss in neuromuscular scoliosis patients as well as to investigate the effect of using a two surgeon approach on specific post-operative complications.

This research study analyses the construction of meaning surrounding the embalmed corpse in contemporary England. It documents a process of social change in which Legal, Medical and Religious discourses concerning the dead, once dominant and unchallenged, now co-exist, if somewhat uneasily, with modern constructions of death and the possibility of an after life. The meaning of the embalmed corpse is considered to be constructed by different elements which are presented historically. Initially religious discourses governed the meaning of the body, which was preserved for religious reasons. 17th century surgeon-embalmers requisitioned the corpse for reasons of status assertion, presenting their arguments in medical terms. Contemporary hygiene issues, in tandem with legal issues, today have a powerful impact on the corpse, which is usually experienced by mourners in the context of contemporary consumer culture, after the process of embalming has occurred. The decline of religious practices also mean that the contemporary corpse has assumed a far greater significance than in the past. From the perspective of the sociology of the body, based on the seminal work of Turner, this thesis discusses how changing experiences of live bodies are inextricably linked with changing experience of dead bodies in contemporary societies. This is accomplished through an interpretation of the different meaning attributed to embalmed corpses, together with an appreciation of the work of Hertz and Van Gennep, both of whom identified, in pre-literate societies, the centrality and embeddedness of the treatment of the corpse to funeral rituals. The thesis reports some empirical investigations of embalming-related issues which provide an analysis of contemporary meanings of the corpse and cast light upon the contemporary structure of the English funeral world. Embalmers expect to produce a culturally acceptable ‘death disguise’ for the benefit of mourners whose encounters with the corpse are surprisingly numerous in contemporary death-denying society. Culturally acceptable death images appear to focus upon the dead being in a condition of 'liminal repose', where the illusion of rest is constructed. Embalmers and funeral directors comprise occupations that are quite distinct, although working with the dead in different parts of the same process. Highlighting the significance of corpse appearance, whereby it is rendered 'normal', has also highlighted the socio-cultural process whereby this transformation occurs. As the dead are carefully re-presented, this has hidden the 'true' condition of the dead and therefore also hidden the covert technicians, embalmers, who accomplish this transformation. Embalming therefore appears a hidden aspect of the social construction of the dead, as death is now estranged from the popular context.

Os fatores intervenientes na satisfaÃÃo e insatisfaÃÃo laboral sÃo diversos, dependem de caracterÃsticas do prÃprio trabalho, bem como da avaliaÃÃo pessoal do trabalhador, e merecem mais estudos sobre o tema. No entanto, identificÃ-los à determinante para se efetivar programas de melhoria da satisfaÃÃo laboral, seja na esfera pÃblica ou privada, com a finalidade de proporcionar maior desempenho profissional e promover mudanÃas positivas na qualidade dos serviÃos prestados. Neste contexto, esta pesquisa caracteriza os principais fatores de SatisfaÃÃo e InsatisfaÃÃo no trabalho dos CirurgiÃes-Dentistas (CD) da EstratÃgia SaÃde da FamÃlia, lotados na Secretaria Executiva Regional III, da Prefeitura Municipal de Fortaleza (PMF), durante o perÃodo da gestÃo 2006-2012, tendo como referencial a Teoria de Frederick Herzberg. Trata-se de um estudo qualitativo com abordagem descritiva e exploratÃria, no qual utiliza como instrumento de coleta de informaÃÃes um roteiro semi-estruturado para entrevista; a tÃcnica de anÃlise do material transcrito foi a AnÃlise de ConteÃdo TemÃtica de Minayo. De modo geral, esta pesquisa corroborou com os estudos de Frederick Herzberg, pois evidenciou que o maior fator de satisfaÃÃo dos respondentes estava correlacionado aos aspectos intrÃnsecos do seu trabalho, ou seja, âo Trabalho em siâ, e os fatores de insatisfaÃÃo associaram-se aos aspectos extrÃnsecos, como as condiÃÃes fÃsicas laborais e a remuneraÃÃo; a pouca valorizaÃÃo dos profissionais tambÃm foi apontada como motivo de insatisfaÃÃo, demonstrando que os cirurgiÃes-dentistas possuem necessidade de serem valorizados e reconhecidos pelo trabalho que realizam. Nesta investigaÃÃo, esse reconhecimento pode vir na direÃÃo dos gestores ou ainda dos pacientes. Observou-se que, 85,7% dos participantes, apesar de todas as adversidades e queixas descritas, demonstraram um nÃvel mediano de satisfaÃÃo no trabalho, nÃo Ãtimo, porque gostavam do que faziam e consideravam isso preponderante para se sentirem satisfeitos. Assim, infere-se que os dentistas das unidades de saÃde da famÃlia, aqui representados por uma amostra de 14 indivÃduos, se identificam e gostam do trabalho que executam, necessitando, sobretudo, de melhorias no ambiente e nas condiÃÃes laborais para que apresentem maior grau de satisfaÃÃo no trabalho.

<p>There is no common understanding on what constitutes good sick-listing, a frequent and problematic task for many physicians, especially general practitioners (GPs) and orthopaedic surgeons. Aiming to achieve a deeper understanding of sick-listing practices, 19 GPs (I, III) and 18 orthopaedic surgeons (II) in four counties were interviewed, and data analysed qualitatively for views on good sickness certification and barriers to desired practice. Data from a survey of all 7665 physicians in two counties on emotionally straining problems in sickness certification (IV) was analysed quantitatively. </p><p>Some GPs exposed narrow views of sick-listing, where their responsibility was limited to issuing a certificate, while GPs with the most inclusive view had a perspective of the patient’s total life-situation and aimed to help patients shoulder their own responsibility (I). The orthopaedic surgeons´ perceptions of good sick-listing were mainly related to their views on their role in the health-care system. Some perceived their responsibility as confined to the orthopaedic clinic only, while others had the ultimate goal of helping the patient to become well functioning in life with regained work capacity – by means of surgery <i>and</i> proper management of sick-listing (II). </p><p>Difficulty handling conflicting opinions was a barrier to good sickness certification for GPs (III), and problematic for about 50% of all physicians and about 80% of GPs (IV). Orthopaedic surgeons’ handling of such situations varied from being directed by the patient, via compromising, to being directed by professional judgement (II). Other barriers included poor stakeholder collaboration (III). GPs with a workplace-policy on sickness certification reported fewer conflicts and less worry of getting reported to the disciplinary board in relation to sick-listing (IV).</p><p>Understanding physicians’ underlying views on and barriers to practicing “good sick-listing” can inform efforts to change physician practice. Communications skills training in handling sick-listing situations with conflicting opinions is recommended.</p>

Bakgrund Postoperativa sårinfektioner orsakar stora kostnader för samhället och orsakar patienterna stort lidande. För att förhindra uppkomsten av infektioner behövs förutom operationssjuksköterskans övergripande ansvar för hygien och sterilitet under operation även att operatören har följsamhet till hygienrutinerna för att förhindra att smittspridning sker. Syfte Att undersöka operationssjuksköterskornas upplevelser av operatörernas följsamhet avseende sterilitet och hygien i samband med kirurgiska ingrepp. Samt att identifiera faktorer som enligt operationssjuksköterskorna kan påverka operatörernas följsamhet och förslag på åtgärder. Metod Kvalitativ design, med semistrukturerade intervjuer med åtta operationssjuksköterskor på två sjukhus i norra Sverige. Induktiv innehållsanalys av Lundman &amp; Hällgren Graneheim (2012) användes för analys av data. Resultat Alla operationssjuksköterskor upplevde att operatörerna brast i sin följsamhet och operationssjuksköterskornas uppfattning var att detta dels berodde på kunskapsluckor hos operatörerna men även kunde härledas till dåligt teamsamarbete och bristande ledning. Operationssjuksköterskorna ansåg att stärkande av operatörernas kompetens, ett stärkt samarbete och en tydligare styrning skulle kunna förbättra följsamheten hos operatörerna. Slutsats Inte endast genom att fylla operatörernas kunskapsluckor kan följsamheten till hygienrutiner förbättras utan det är även av betydande vikt att teamsamarbetet förbättras. / Background Postoperative wound infections cause major costs to society and causes patients great suffering. To prevent the occurrence of infections surgeon adherence to hygiene routines, in addition to the operating room nurse overall responsibility for hygiene and sterility during surgery, is needed. Aim To investigate surgical nurses experiences of surgeons adherence regarding sterility and hygiene during surgical procedures. And identify factors that according to surgical nurses can affect surgeons' adherence and proposed actions. Method Qualitative design, with semi-structured interviews with eight surgical nurses at two hospitals in northern Sweden. Inductive content analysis of Lundman &amp; Hällgren Graneheim (2012) was used for analysis of data. Result All surgical nurses experienced surgeons to fail in adherence and the surgical nurses opinion was that this is partly due to knowledge gaps among surgeons, but that it could also be attributed to poor team cooperation and lack of leadership. The surgical nurses felt that strengthening of the surgeon's skills, strengthened cooperation and a more distinct leadership could improve adherence among surgeons. Conclusion Not only by addressing the surgeon's knowledge gaps can adherence to hygiene be improved but it is also of significant importance to improve team collaboration.

Esta pesquisa tem como enfoque central a especificidade do trabalho do cirurgiãodentista (CD), na atenção primária em saúde e, como objeto de estudo, a construção de suas competências gerais e específicas e sua contribuição para a construção do Sistema Único de Saúde (SUS). Os referenciais de competência e atenção primária em saúde, articulados aos princípios do SUS e da estratégia de Saúde da Família, fundamentaram teoricamente este trabalho. A definição dos municípios do estudo e da escolha dos sujeitos deu-se em função da utilização da técnica Delphi, como método de investigação. Foram selecionados 12 municípios da Região do Triângulo Mineiro/ Alto Paranaíba e a totalidade dos 509 cirurgiões-dentistas da rede básica do SUS. Participaram da pesquisa 11 municípios e 337 cirurgiões-dentistas. Os resultados em relação ao perfil dos CD apontaram que a maioria é de mulheres (69,5%); tem a idade de mais de 36 anos (70%); casados (65%); estão a longo período trabalhando na atenção básica de saúde (53% acima de 10 anos); e em busca da diferenciação neste contexto de mercado, a partir da realização da pósgraduação (especialização), sendo que 55,8% cursaram ou estão cursando a especialização e 3,6% são mestres. As 20 competências analisadas, dentre as gerais e as específicas, foram selecionadas pelo Painel Delphi, como apropriadas e relevantes para o cirurgiãodentista na atenção primária em saúde, obtendo níveis de concordância, parcial e total, acima de 83%. As mesmas agruparam-se com tendência de maior valorização nas categorias definidas como (a) competências técnicas e de serviço: conhecimento técnico-científico com intervenção clínica humanizada; diagnóstico preciso; coordenação e execução de ações coletivas de promoção e prevenção em saúde; promoção e educação em saúde; educação permanente; execução de visitas domiciliares qualificadas; atendimento adequado a grupos específicos; atenção odontológica com enfoque para gestantes e bebês; interação e conhecimento da comunidade que atua; trabalho em equipe multiprofissional e habilidade manual, em (b) competências pessoais e comunicativas: criatividade e capacidade de adaptação; criatividade com iniciativa e flexibilidade; liderança; segurança e confiança, em (c) competências do cuidado e organizacionais ou metódicas: acolhimento ao usuário e humanização; planejamento em saúde; gerenciamento e organização. Em contraponto, o menor percentual de concordância (83.1%) correspondeu a competência responsabilidade social, alocada neste estudo na (d) categoria sóciopolítica. As competências requeridas para o trabalho do cirurgião dentista na atenção primária em saúde fazem parte, indispensável, junto a um conjunto de demais ações estratégicas, que possibilitam o suporte necessário para a construção do SUS. Estas competências devem atender as necessidades de articulação da prática e da formação do CD, em uma perspectiva dos atributos essenciais da Atenção Primária em Saúde (APS) em interface com os princípios do SUS e da estratégia de Saúde da Família, com ênfase no cuidado à saúde e na responsabilidade social. / The main focus of this study is the specificity of dental surgeons work in primary health care, looking at the development of their general and specific competencies and their contribution to the construction of the Brazilian Single Health System (SUS). Competence and primary health care, articulated with the principles of the SUS and the Family Health strategy, served as the theoretical reference framework for this study. The definition of study cities and the choice of study subjects occurred in function of the use of the Delphi technique as the research method. Twelve cities were selected from the Triângulo Mineiro/Alto Paranaíba region, Brazil, and a total of 509 SUS dental surgeons (DS). Eleven cities and 337 dental surgeons participated in the study. Regarding the profile of the DS, the results indicated that most of them are women (69.5%); older than 36 (70%); married (65%); working in primary health care for a long time (53% more than 10 years) and seeking graduate programs (specialization) as a means to differentiate themselves in this labor market context, with 55.8% who attended or are attending specialization courses and 3.6% with a master s degree. Twenty specific and general competencies were analyzed, which were selected by the Delphi panel as appropriated and relevant for dental surgeons in primary health care, obtaining partial and total agreement levels above 83%. They were grouped according to their higher valuation tendencies in the categories defined as (a) technical and service competencies: technical-scientific knowledge with humanized clinical intervention; precise diagnostic; coordination and execution of collective health promotion and prevention actions; health promotion and education; permanent education; qualified home visits; adequate care to specific groups; dental care focusing on pregnant women and babies; knowledge and interaction with the community the professionals work in; multi-professional team work and manual ability; (b) personal and communicative competencies: creativity and adaptive capacity; creativity with initiative and flexibility; leadership; safety and trust; (c) care and organizational or methodical competencies: welcoming the user and humanization; health planning; management and organization. In counterpart, the lowest agreement percentage (83.1%) was found for the social responsibility competence, located in the (d) sociopolitical category. The competencies required of dental surgeons in primary health care are an indispensable part of a set of strategic actions, which provide the necessary support for the construction of the SUS. These competencies should meet the needs to articulate dental surgeons? practice and education, within the perspective of essential primary health care (PHC) attributes at the interface with SUS and the Family Health strategy principles, emphasizing health care and social responsibility.

Na história recente, o exercício da profissão de Cirurgião-Dentista tem sido alvo de inúmeras ações judiciais das mais diversificadas, impetradas por pacientes descontentes com os resultados obtidos em seus tratamentos odontológicos. Considerando os direitos inerentes à pessoa do paciente e a enorme preocupação da classe odontológica com relação às demandas judiciais originadas pela falta de informação adequada a seus pacientes, alguns aspectos importantes do Consentimento Informado bem como da própria responsabilidade civil odontológica estão abordados neste estudo, a fim de esclarecer e evitar as constantes demandas judiciais contra dentistas por falta de um termo de Consentimento Informado. A informação, seja verbal ou escrita, sobre um diagnóstico, procedimento terapêutico, ou tratamento odontológico aos pacientes ou familiares, e a forma como explicar de maneira compreensiva o que está sendo repassado é um grande conflito entre a classe odontológica nos dias atuais. O Consentimento Informado e o Termo de Consentimento Livre e Esclarecido vem ser a forma, verbal e escrita de como o cirurgião-dentista informa o seu paciente ou representante, de modo límpido, os atos e etapas, relacionados ao diagnóstico e ao seu tratamento terapêutico, esclarecendo os riscos e benefícios, vantagens e desvantagens de forma que possa, autonomamente, escolher por realizar, ou não, o possível tratamento. O objetivo deste trabalho foi realizar o levantamento e análise das decisões recursais dos Tribunais de Justiça do sul do Brasil, utilizando a Internet. Dos 102 acórdãos avaliados 30 são do Tribunal de Justiça do Paraná, 17 do Tribunal de Justiça de Santa Catarina e 55 do Tribunal de Justiça do Rio Grande do Sul. Em relação ao Consentimento Informado, Termo de Consentimento Livre e Esclarecido ou mesmo a prova da Informação, constatou-se que nos referidos acórdãos estes assuntos foram pouco citados, porém observou-se que quando mencionados serviram de subsídios consistentes para defesa do profissional. / In recent history, the profession of dental surgeon has been the target of numerous lawsuits from more diverse, filed by patients dissatisfied with the results obtained in their dental treatment. Considering the inherent rights of the patient and the dental class of great concern with respect to lawsuits stem from the lack of adequate information to their patients, some important aspects of informed consent as well as from civil liability in dentistry are addressed in this study in order to clarify and avoid the constant lawsuits against dentists by a lack of informed consent The information, whether oral or written, about a diagnosis, therapeutic procedure, or dental treatment to patients or relatives, and how to comprehensively explain what is being passed is a major conflict between the dental class nowadays. Informed Consent and the Term of Consent has to be the case, verbal and written like the dentist tells the patient or his representative, so clear, the actions and steps, related to diagnosis and therapeutic treatment, accounting the risks and benefits, advantages and disadvantages so that you can, independently, choose to perform, or not, the possible treatment. The aim of this study was to survey and analysis of appellate decisions of the Courts of Justice in southern Brazil, using the Internet. Of the 102 judgments are assessed 30 of the Court of Paraná, 17 of the Court of St. Catherine and 55 of the Court of Rio Grande do Sul. Regarding Informed Consent, Termination of Consent or even proof of Information it was found that the judgments were seldom mentioned these issues, but noted that when mentioned served as subsidies for consistent defense of the professional.

There is no common understanding on what constitutes good sick-listing, a frequent and problematic task for many physicians, especially general practitioners (GPs) and orthopaedic surgeons. Aiming to achieve a deeper understanding of sick-listing practices, 19 GPs (I, III) and 18 orthopaedic surgeons (II) in four counties were interviewed, and data analysed qualitatively for views on good sickness certification and barriers to desired practice. Data from a survey of all 7665 physicians in two counties on emotionally straining problems in sickness certification (IV) was analysed quantitatively. Some GPs exposed narrow views of sick-listing, where their responsibility was limited to issuing a certificate, while GPs with the most inclusive view had a perspective of the patient’s total life-situation and aimed to help patients shoulder their own responsibility (I). The orthopaedic surgeons´ perceptions of good sick-listing were mainly related to their views on their role in the health-care system. Some perceived their responsibility as confined to the orthopaedic clinic only, while others had the ultimate goal of helping the patient to become well functioning in life with regained work capacity – by means of surgery and proper management of sick-listing (II). Difficulty handling conflicting opinions was a barrier to good sickness certification for GPs (III), and problematic for about 50% of all physicians and about 80% of GPs (IV). Orthopaedic surgeons’ handling of such situations varied from being directed by the patient, via compromising, to being directed by professional judgement (II). Other barriers included poor stakeholder collaboration (III). GPs with a workplace-policy on sickness certification reported fewer conflicts and less worry of getting reported to the disciplinary board in relation to sick-listing (IV). Understanding physicians’ underlying views on and barriers to practicing “good sick-listing” can inform efforts to change physician practice. Communications skills training in handling sick-listing situations with conflicting opinions is recommended.

The adoption of Minimally Invasive Surgery (MIS) and Robot-Assisted MIS has resulted in the distortion of haptic cues surgeons rely on. The application of excessive force during port creation has lead to increased surgical access trauma. This study aims to quantify the forces experienced during port creation with a blunt-ended Threaded Visual Cannula (TVC) in an effort to ameliorate patient safety, provide a quantitative platform for surgeon training, and offer a gateway for the eventual automation of this problematic aspect of MIS. A method of determining the torque encountered during port creation was established. It was found that the magnitude of torque required to cannulate different materials was unique and was dictated by the friction observed at the tool/tissue interface. Furthermore, the ability to detect instantaneous changes in torque arising from the transition between two different media was not found to be possible with the current design of the TVC.

The adoption of Minimally Invasive Surgery (MIS) and Robot-Assisted MIS has resulted in the distortion of haptic cues surgeons rely on. The application of excessive force during port creation has lead to increased surgical access trauma. This study aims to quantify the forces experienced during port creation with a blunt-ended Threaded Visual Cannula (TVC) in an effort to ameliorate patient safety, provide a quantitative platform for surgeon training, and offer a gateway for the eventual automation of this problematic aspect of MIS. A method of determining the torque encountered during port creation was established. It was found that the magnitude of torque required to cannulate different materials was unique and was dictated by the friction observed at the tool/tissue interface. Furthermore, the ability to detect instantaneous changes in torque arising from the transition between two different media was not found to be possible with the current design of the TVC.