Effects of cobalt-chromium everolimus eluting stents or bare metal stent on fatal and non-fatal cardiovascular events: patient level meta-analysis

Objectives: To examine the safety and effectiveness of cobalt-chromium everolimus eluting stents compared with bare metal stents. Design: Individual patient data meta-analysis of randomised controlled trials. Cox proportional regression models stratified by trial, containing random effects, were used to assess the impact of stent type on outcomes. Hazard ratios with 95% confidence interval for outcomes were reported. Data sources and study selection: Medline, Embase, the Cochrane Central Register of Controlled Trials. Randomised controlled trials that compared cobalt-chromium everolimus eluting stents with bare metal stents were selected. The principal investigators whose trials met the inclusion criteria provided data for individual patients. Primary outcomes: The primary outcome was cardiac mortality. Secondary endpoints were myocardial infarction, definite stent thrombosis, definite or probable stent thrombosis, target vessel revascularisation, and all cause death. Results: The search yielded five randomised controlled trials, comprising 4896 participants. Compared with patients receiving bare metal stents, participants receiving cobalt-chromium everolimus eluting stents had a significant reduction of cardiac mortality (hazard ratio 0.67, 95% confidence interval 0.49 to 0.91; P=0.01), myocardial infarction (0.71, 0.55 to 0.92; P=0.01), definite stent thrombosis (0.41, 0.22 to 0.76; P=0.005), definite or probable stent thrombosis (0.48, 0.31 to 0.73; P<0.001), and target vessel revascularisation (0.29, 0.20 to 0.41; P<0.001) at a median follow-up of 720 days. There was no significant difference in all cause death between groups (0.83, 0.65 to 1.06; P=0.14). Findings remained unchanged at multivariable regression after adjustment for the acuity of clinical syndrome (for instance, acute coronary syndrome v stable coronary artery disease), diabetes mellitus, female sex, use of glycoprotein IIb/IIIa inhibitors, and up to one year v longer duration treatment with dual antiplatelets. Conclusions: This meta-analysis offers evidence that compared with bare metal stents the use of cobalt-chromium everolimus eluting stents improves global cardiovascular outcomes including cardiac survival, myocardial infarction, and overall stent thrombosis.

Effects of cobalt-chromium everolimus eluting stents or bare metal stent on fatal and non-fatal cardiovascular events: patient level meta-analysis

Objectives: To examine the safety and effectiveness of cobalt-chromium everolimus eluting stents compared with bare metal stents. Design: Individual patient data meta-analysis of randomised controlled trials. Cox proportional regression models stratified by trial, containing random effects, were used to assess the impact of stent type on outcomes. Hazard ratios with 95% confidence interval for outcomes were reported. Data sources and study selection: Medline, Embase, the Cochrane Central Register of Controlled Trials. Randomised controlled trials that compared cobalt-chromium everolimus eluting stents with bare metal stents were selected. The principal investigators whose trials met the inclusion criteria provided data for individual patients. Primary outcomes: The primary outcome was cardiac mortality. Secondary endpoints were myocardial infarction, definite stent thrombosis, definite or probable stent thrombosis, target vessel revascularisation, and all cause death. Results: The search yielded five randomised controlled trials, comprising 4896 participants. Compared with patients receiving bare metal stents, participants receiving cobalt-chromium everolimus eluting stents had a significant reduction of cardiac mortality (hazard ratio 0.67, 95% confidence interval 0.49 to 0.91; P=0.01), myocardial infarction (0.71, 0.55 to 0.92; P=0.01), definite stent thrombosis (0.41, 0.22 to 0.76; P=0.005), definite or probable stent thrombosis (0.48, 0.31 to 0.73; P<0.001), and target vessel revascularisation (0.29, 0.20 to 0.41; P<0.001) at a median follow-up of 720 days. There was no significant difference in all cause death between groups (0.83, 0.65 to 1.06; P=0.14). Findings remained unchanged at multivariable regression after adjustment for the acuity of clinical syndrome (for instance, acute coronary syndrome v stable coronary artery disease), diabetes mellitus, female sex, use of glycoprotein IIb/IIIa inhibitors, and up to one year v longer duration treatment with dual antiplatelets. Conclusions: This meta-analysis offers evidence that compared with bare metal stents the use of cobalt-chromium everolimus eluting stents improves global cardiovascular outcomes including cardiac survival, myocardial infarction, and overall stent thrombosis.

Conversioni al cattolicesimo a Roma tra Sei e Settecento. La presenza degli scandinavi nell’Ospizio dei Convertendi.

In my PhD dissertation, I have examined a group of people of Scandinavian origin received by Ospizio dei Convertendi. This group has been hitherto largely unknown to historical research. The Ospizio was an institute founded by the Oratorian Congregation in Rome in 1673 to provide religious instruction and material aid to both recent and aspirant converts to Roman Catholicism. My research traces the profile of converts and a typology of motives, examining different factors which influenced the conversion process. I show that the key factors were often of a social rather than a religious nature. Moreover, I have analyzed the hospice in the context of Counter-Reformation charity as well. In terms of numbers, the Scandinavians formed a somewhat marginal yet not insignificant group within the Roman hospice. Out of a total of 2203 guests received between 1673 and 1706, 4.6 % were Scandinavians: 74 Swedes (including Finland and Livonia) and 27 Danes (including Norway). They came from a rigorously Protestant region which reacted to Catholicism with severe legislative measures. Converts to Catholicism risked confiscation of their goods, expulsion or even capital punishment. Since both Sweden and Denmark were practically impenetrable to Catholicism at the time and clandestine missionary attempts often failed before they had even properly started, the Roman Catholic Church shifted its interest towards Northerners arriving in Rome, a preferred destination for young noblemen, artists and migrant craftsmen. The material related to Ospizio dei Convertendi, conserved in the Vatican archives, is a scarcely known yet unusually rich source, not only for the religious history of our continent, but also for social history and the study of migration in early modern Europe. It contains a wealth of information about members of the subordinate classes, of their travels and lives in Europe. The profile delineated in these documents is of individuals who had a wide range of different professions and different aspirations. These documents encompass a vast social spectrum that was highly mobile on a continent which by that time had become pluriconfessional. Therefore, these migrants faced the complex religious reality in their everyday life. The principal corpus of my research consists of two types of manuscript sources created for administrative and in a way also for apologetic purposes of the Roman Catholic Church. My starting point is the Primo registro generale of Ospizio dei Convertendi. This is a volume in which the following information about each guest was registered: name, nationality, city of origin, age, sex, profession, confession professed before converting, date of arrival, departure, abjuration and baptism. Typically, the convert was male, originating from Stockholm or Copenhagen, from 21 to 30 years of age. The biggest occupational groups in descending order were soldiers, noblemen, craftsmen and sailors. Thus the data reflects a multiform reality of interurban and long distance migration, ideals regarding the education of young noblemen and gentry as well as the need of European armies to hire foreign mercenaries in their various campaigns. Against this background the almost total absence of women is hardly surprising: there is only one woman in the material I have studied. The second main source, Nota degl’ospiti ricevuti e spese fatte per essi, sheds more light on the choices of the converts, their motivations and their lives outside Scandinavia before reaching Rome. This narrative material permits an analysis which completes but also goes far beyond the columns of the Institute’s general register. This material consists of reports written by Catholic priests based on an interview conducted upon each guest’s arrival. The material frequently includes information on what the converts would do following their departure from the Institute as well. These sources have a specific narrative form and contain short biographies, list reasons for converting and information about the journey from the North to the Mediterranean - a journey which in many cases took several years. Moreover, they show that certain unorthodox practices such as calling on the saints and pleading for help from them were not uncommon in the Protestant popular religion. The recording of information on conversions from Protestantism to Catholicism reflects both religious and social interest on the part of the receiving institute. The information obtained was used for the purposes of religious teaching, for finding adequate ways of inserting the convert into Italian society so that he could earn a living, and to find effective methods to convert others with a similar cultural and geographical background. The stories recorded were based on interviews with the newly-arrived, information obtained from a travel companion or fellow countrymen, or from written documents the aspirant converts carried with them. These sources illustrate, although sometimes in rather simplified ways, the circumstances and motivations which were relevant to the choice of changing one’s confession. In addition, I have examined petitions addressed to the hospice and other Roman authorities in order to get financial aid. These petitions were written by Italian scrittori, and they contain certain conventions and topoi of presenting the conversion with the purpose of improving the chances of obtaining financial aid. It is through these filters, which may seem initially almost invisible, that the remote voice of the converts reaches us. The results of the analysis are particularly interesting because they disagree with some of the principal conclusions of previous work on the subject. First, earlier research has focused almost exclusively on the conversions of noblemen, and has argued, second, that the Queen Christina of Sweden was the driving force behind their change of confession. The sources examined for this dissertation present a profile of long-distance migrants, many of them members of the subordinate classes, who were looking for ways to make their living in Europe. These people had in many cases left their country of origin several years earlier and not for religious reasons, so, crucially, we are not dealing with confessional migration in these cases. Rather, conversion was a complex process, intricately tied up with strategies of survival, integration and upward social mobility. At the same time, while these components are significant on their own right, they do not necessarily point to the absence of motivations of a more clearly religious nature.

Citrus exocortis viroid and Hop Stunt viroid Doubly infecting grapevines in Brazil

Viroids, non-protein-coding small (246-401 nt) circular single-stranded RNAs with autonomous replication, are currently classified into two families. Within the family Pospiviroidae, Citrus exocortis viroid (CEVd) belongs to the genus Pospiviroid while Hop stunt viroid (HSVd) is the single member of the genus Hostuviroid. These pathogens are distributed worldwide and infect a large number of hosts. In Brazil, isolates of CEVd and HSVd have been detected in both citrus and grapevine. To characterize and study the genetic variability of these viroids, total RNA from leaves of grapevine Vitis vinifera 'Cabernet Sauvignon' and V. labrusca 'Niagara Rosada' from Bento Gonçalves, RS, was used as a template for RT-PCR amplification with specific primers for the five viroids described infecting grapevines [HSVd, CEVd, Grapevine yellow speckle viroid 1 (GYSVd-1), Grapevine yellow speckle viroid 2 (GYSVd-2) and Australian grapevine viroid (AGVd)]. Leaf samples of Citrus medica infected with CEVd from São Paulo were also analyzed. The resulting products were separated by agarose gel electrophoresis and DNA fragments of the expected size were eluted, cloned and sequenced. The grapevine samples analyzed were doubly infected by CEVd and HSVd. A phylogenetic analysis showed that the Brazilian grapevine HSVd variants clustered with other grapevine HSVd variants, forming a specific group separated from citrus variants, whereas the Brazilian CEVd variants clustered with other citrus and grapevine variants.

Comparison Structure Analysis

This study presents an automatic, computer-aided analytical method called Comparison Structure Analysis (CSA), which can be applied to different dimensions of music. The aim of CSA is first and foremost practical: to produce dynamic and understandable representations of musical properties by evaluating the prevalence of a chosen musical data structure through a musical piece. Such a comparison structure may refer to a mathematical vector, a set, a matrix or another type of data structure and even a combination of data structures. CSA depends on an abstract systematic segmentation that allows for a statistical or mathematical survey of the data. To choose a comparison structure is to tune the apparatus to be sensitive to an exclusive set of musical properties. CSA settles somewhere between traditional music analysis and computer aided music information retrieval (MIR). Theoretically defined musical entities, such as pitch-class sets, set-classes and particular rhythm patterns are detected in compositions using pattern extraction and pattern comparison algorithms that are typical within the field of MIR. In principle, the idea of comparison structure analysis can be applied to any time-series type data and, in the music analytical context, to polyphonic as well as homophonic music. Tonal trends, set-class similarities, invertible counterpoints, voice-leading similarities, short-term modulations, rhythmic similarities and multiparametric changes in musical texture were studied. Since CSA allows for a highly accurate classification of compositions, its methods may be applicable to symbolic music information retrieval as well. The strength of CSA relies especially on the possibility to make comparisons between the observations concerning different musical parameters and to combine it with statistical and perhaps other music analytical methods. The results of CSA are dependent on the competence of the similarity measure. New similarity measures for tonal stability, rhythmic and set-class similarity measurements were proposed. The most advanced results were attained by employing the automated function generation – comparable with the so-called genetic programming – to search for an optimal model for set-class similarity measurements. However, the results of CSA seem to agree strongly, independent of the type of similarity function employed in the analysis.

Essays on Business and Leadership Ethics

As this is a dissertation, an academic thesis, it is important to define the objectives of my research, even if ex post facto, explicitly: - To define, develop and study the concept of business and leadership ethics. - To empirically study the phenomena associated with business and leadership from an ethical perspective. - To create a new framework for the development of responsible business. - To create an “acid test” for my body of works, i.e. a test and an evaluation on how well my research and ideas hold up under academic philosophical reflection. The utilitarian reasoning had the most support when the actors justified their actions regarding economic benefit. (=instrumental good). Duty and benefit were often mixed up in people’s speech. Their meaning contents were blurred and the argumentation lines created by the actors were broken. This can be interpreted in a way that supports Frankena’s mixed deontological philosophy as a frame of reference. Deontologica reasoning was used e.g. in describing the personnel management processes of a company. Virtue ethics is a favourable starting point for studying management and leadership ethics. All the actors studied could name virtues for their operations, towards which to aspire to. They also named professional practices already in use that they considered to be virtuous. Finally, I wish to state that normative ethics is an important branch of philosophical ethics, if also very important in applied ethics especially. From the normative standpoint, the results of this dissertation want to lead nations, communities and individuals towards the virtues of democratic leadership and sustainable economic development.

”Du sköna sång, vårt bästa arv” - kanonisering av en sångskatt ur ett hermeneutiskt perspektiv

Songs have the power to get through to people. When lyrics are combined with a tune, the result is an entity where the first few notes of a melody can evoke emotions of recognition and belonging. A song treasury consists of such songs that are part of a canonized song tradition. The process where certain songs become part of an established song treasury is long, and many other aspects than the tune itself influence the forming of a song treasury. By examining the characteristics of a song tradition, the history of an ethnic group can be illuminated. In this study, music, pedagogy, and the sociocultural context are merged into a whole where a common song tradition, the song treasury, is in focus. The main aim of this study is to deepen the understanding of a song treasury, its development and contents. This understanding is accomplished by analyzing the musical and lyrical characteristics of 60 songs, which have been sung in schools, homes, and communities, thereby becoming popular among the Swedish-speaking Finns during the 20th century. The songs have been chosen by combining three song lists, of which two lists are closely related to school curricula. The third song list is a result of a survey on favourite songs, according to the situation around year 2000. The songs are examined in their notated versions, a number of song books and text books (n = 29) forming the empirical material. In this study, a hermeneutical approach is applied, content analysis being the method. The analysis is based on three perspectives: the sociocultural perspective, the music-pedagogical perspective, and the musico-analytical perspective. Within each perspective, two aspects are studied. This results in a hexagonal model which forms the structure of the study as a whole. The first two perspectives form the background; a historical context where nation, education, home country, and homestead are regarded as highly important. A common song repertoire is considered to be an effective means of building collective identity within ethnic groups, the common language and the cultural heritage being used as rhetorical arguments. During the early 1900s, choir festivals become an educational platform where conceptions of a common belonging are developed and strengthened through religious, patriotic, and poetical expressions. National school curricula in singing and music have similar characteristics, cultural heritage and values education being in focus. The song lyrics often describe nature and emotions, and they also appear to be personal and situated in a given time and place. Patriotic expressions and songs about music are also fairly common. The songs generally express positive attitudes, which are intensified by major tonality, rich and varied melodies with stable rhythms, and a strong tonal base. The analyzed details of the studied aspects are merged into a thick description, which results in an interpretation pattern with three dimensions: a song treasury can be considered an expression of collective identity, cultural heritage, and values education.

Corporate Social Responsibility and Shipping Views of Baltic Sea Shipping Companies on the Benefits of Responsibility

The safety of shipping operations in the Baltic Sea is an extensively studied issue due to the density of traffic and the ecological sensitivity of the area. The focus has, however, mainly been on ship technology or on traffic control measures and the operative safety aspect of shipping is in a minor position in maritime safety studies and is lacking in terms of solutions. Self-regulatory and voluntary measures could be effective ways to improve the operational safety of shipping. Corporate social responsibility, or CSR, is one example of a voluntary measure that the shipping companies can take. CSR can enhance maritime safety and improve the shipping companies’ competitiveness. The aim of this study is to increase the knowledge of CSR in the maritime sector and study its applicability and benefits to the shipping companies. The research comprises of a theory part and a questionnaire study, which examine the significance of corporate social responsibility in shipping companies’ maritime safety and competitiveness. The aim of the questionnaire study is to find out how corporate social responsibility is implemented in the shipping companies. According to the literature review, responsible actions can produce financial and time costs, but due to these actions cost savings in the form of learning and increased efficiency can be achieved. Responsible actions can also produce concrete improvements and a reputation of responsibility that can lead to both cost savings and increase in the company’s income. CSR is recognised as having real business benefits in terms of attracting customers and high-quality employees. In shipping, CSR usually focuses on environmental issues. Environmental social responsibility in shipping is mainly motivated by the need to comply with existing and forthcoming regulation. Shipping companies engage in CSR to gain competitive advantage and to increase maritime safety. The social aspects of CSR take into account the well-being and skills of the employees, corporation and other stakeholders of the company. The questionnaire study revealed that the most common CSR measures in shipping companies are environmental measures, and that environmental concerns are considered to be the most important reason to engage in CSR. From the preliminary question about the concept of CSR it can also be seen that safety issues are commonly considered to be a part of CSR and safety gains are the second most important reason to engage in CSR. From the questionnaire, it can also be extrapolated that gaining a better reputation is one of the most important reasons to engage in CSR in the first place. For example, the main economic benefit was seen to be the increase of customer numbers as a result of a better reputation. Based on the study, it would seem that companies are starting to realise that they might gain competitive advantage and be favoured as shippers if they engage in sustainable, responsible operations and present themselves as “green”.

Crystallization of selected anions and cations from mine waters

The aim of this Master’s thesis was to review some methods that are already being utilized in a field of mine water purification and to find and study possible new methods and chemicals for mine water purification by precipitation. The target was also to list the optimal process conditions for these precipitating chemicals. Separation methods were reviewed for several anions and cations, but being a real topical issue, sulphate removal was selected to be in the main focus. Sulphate salts e.g. Na2SO4 are relatively soluble in water, which makes the separation processes difficult. Eutectic freeze crystallization was studied more closely in laboratory tests for sodium sulphate removal. Gravimetric solubility tests were made for three cases of mixed electrolyte solutions: Na2SO4 – NaOH, BaSO4 – NaOH and Na3PO4 – NaOH. The aim of these experiments was to study the effect of NaOH addition on solubility of the studied salt. These phenomena were however noticed to be difficult to see in the used laboratory tests. Thus mathematical modelling was utilized to contribute the laboratory experiments and to bring additional information of the influence of NaOH presence on solubility of selected electrolytes, Na2SO4 and Na3PO4. The results from mathematical modelling of activity coefficients suggest Na2SO4 and Na3PO4 to be precipitated rather with presence and with higher concentrations of NaOH, since the raise of NaOH concentration decreases the solubility of these electrolytes in water.

Reaching influential early adopters effectively in Finland : Rock Science – new generation board game

Innovations diffuse at different speed among the members of a social system through various communication channels. The group of early adopters can be seen as the most influential reference group for majority of people to base their innovation adoption decisions on. Thus, the early adopters can often accelerate the diffusion of innovations. The purpose of this research is to discover means of diffusion for an innovative product in Finnish market through the influential early adopters in respect to the characteristics of the case product. The purpose of the research can be achieved through the following sub objectives:  Who are the potential early adopters for the case product and why?  How the potential early adopters of the case product should be communicated with?  What would be the expectations, preferences, and experiences of the early adopters of the case product? The case product examined in this research is a new board game called Rock Science which is considered to be incremental innovation bringing board gaming and hard rock music together in a new way. The research was conducted in two different parts using both qualitative and quantitative research methods. This mixed method research began with expert interviews of six music industry experts. The information gathered from the interviews enabled researcher to compose the questionnaire for the quantitative part of the study. Internet survey that was sent out resulted with a sample of 97 responses from the targeted population. The key findings of the study suggest that (1) the potential early adopters for the case product are more likely to be young adults from the capital city area with great interest in rock music, (2) the early adopters can be reached effectively through credible online sources of information, and (3) the respondents overall product feedback is highly positive, except in the case of quality-price ratio of the product. This research indicates that more effective diffusion of Rock Science board game in Finland can be reached through (1) strategic alliances with music industry and media partnerships, (2) pricing adjustments, (3) use of supporting game formats, and (4) innovative use of various social media channels.

Evaluation of behavioral states among morning and evening active healthy individuals

The Horne-Östberg questionnaire partly covers some factors that may be important determinants of peak time and characterize patterns of behavior. We conducted a study for the evaluation of self-reported behavioral states (hunger sensation, availability for study, physical exercise, solving daily problems, and time preferences) as expressions of underlying cyclic activity. Three hundred and eighteen community subjects without history of medical, psychiatric, or sleep disorders were evaluated in a cross-sectional design. A self-report about daily highest level of activity was used to categorize individuals into morning, evening, and indifferently active. Time-related behavioral states were evaluated with 23 visual analog questions. The responses to most analogic questions were significantly different between morning and evening active subjects. Logistic regression analysis identified a group of behaviors more strongly associated with the self-reported activity pattern (common wake up time, highest subjective fatigue, as well as wake up, bedtime, exercise and study preferences). These findings suggested that the patterns of activity presented by normal adults were related to specific common behavioral characteristics that may contribute to peak time.

Value based pricing and marketing of marine engines

Objective of the thesis is to create a value based pricing model for marine engines and study the feasibility of implementing such model in the sales organization of a specific segment in the case company’s marine division. Different pricing strategies, concept of “value”, and how perceptions of value can be influenced through value based marketing are presented as theoretical background for the value based pricing model. Forbis and Mehta’s Economic Value to Customer (EVC) was selected as framework to create the value based pricing model for marine engines. The EVC model is based on calculating and comparing life-cycle costs of the reference product and competing products, thus showing the quantifiable value of the company’s own product compared to competition. In the applied part of the thesis, the components of the EVC model are identified for a marine diesel engine, the components are explained, and an example calculation created in Excel is presented. When examining the possibilities to implement in practice a value based pricing strategy based on the EVC model, it was found that the lack of precise information on competing products is the single biggest obstacle to use EVC exactly as presented in the literature. It was also found that sometimes necessary communication channels are missing and that there is simply a lack of interest from some clients and product end-users part to spend time on studying the life-cycle costs of the product. Information on the company’s own products is however sufficient and the sales force is capable to communicate to sufficiently high executive levels in the client organizations. Therefore it is suggested to focus on quantifying and communicating the company’s own value proposition. The dynamic nature of the business environment (variance in applications in which engines are installed, different clients, competition, end-clients etc.) means also that each project should be created its own EVC calculation. This is demanding in terms of resources needed, thus it is suggested to concentrate on selected projects and buyers, and to clients where the necessary communication channels to right levels in the customer organization are available. Finally, it should be highlighted that as literature suggests, implementing a value based pricing strategy is not possible unless the whole business approach is value based.

Cardiovascular health from childhood to adulthood – with special reference to early vascular changes. The Cardiovascular Risk in Young Finns Study

Background: Recent recommendations aim to improve cardiovascular health (CVH) by encouraging the general population to meet positive and modifiable ideal CVH metrics: not smoking, being physically active, and maintaining normal weight, blood pressure, blood glucose and total cholesterol levels and a healthy diet. Aims: The aim of the present study was to report the prevalence of ideal CVH in children and young adults and study the associations of CVH metrics with markers of subclinical atherosclerosis. Participants and methods: The present thesis is part of the Cardiovascular Risk in Young Finns Study (Young Finns Study). Data on associations of CVH metrics and subclinical atherosclerosis were available from 1,898 Young Finns Study participants. In addition, joint analyses were performed combining data from the International Childhood Cardiovascular Cohort (i3C) Consortium member studies from Australia and the USA. Results: None of the participants met all 7 CVH metrics and thus had ideal CVH in childhood and only 1% had ideal CVH as young adults. The number of CVH metrics present in childhood and adulthood predicted lower carotid artery intima-media thickness, improved carotid artery distensibility and lower risk of coronary artery calcification. Those who improved their CVH status from childhood to adulthood had a comparable risk of subclinical atherosclerosis to participants who had always had a high CVH status. Conclusions: Ideal CVH proved to be rare among children and young adults. A higher number of ideal CVH metrics and improvement of CVH status between childhood and adulthood predicted a lower risk of subclinical atherosclerosis.

Long-term efficacy of a rural community-based integrated intervention for prevention and management of chronic obstructive pulmonary disease: a cluster randomized controlled trial in China's rural areas

This study aimed to assess the efficacy of a rural community-based integrated intervention for early prevention and management of chronic obstructive pulmonary disease (COPD) in China. This 18-year cluster-randomized controlled trial encompassing 15 villages included 1008 patients (454 men and 40 women in the intervention group [mean age, 54 ± 10 years]; 482 men and 32 women in the control group [mean age, 53 ± 10 years]) with confirmed COPD or at risk for COPD. Villages were randomly assigned to the intervention or the control group, and study participants residing within the villages received treatment accordingly. Intervention group patients took part in a program that included systematic health education, smoking cessation counseling, and education on management of COPD. Control group patients received usual care. The groups were compared after 18 years regarding the incidence of COPD, decline in lung function, and mortality of COPD. COPD incidence was lower in the intervention group than in the control group (10% vs 16%, <0.05). A decline in lung function was also significantly delayed in the intervention group compared to the control group of COPD and high-risk patients. The intervention group showed significant improvement in smoking cessation compared with the control group, and smokers in the intervention group had lower smoking indices than in the control group (350 vs 450, <0.05). The intervention group also had a significantly lower cumulative COPD-related death rate than the control group (37% vs 47%, <0.05). A rural community-based integrated intervention is effective in reducing the incidence of COPD among those at risk, delaying a decline in lung function in COPD patients and those at risk, and reducing mortality of COPD.

Socially shared metacognitive regulation during collaborative learning processes in student dyads and small groups

Traditionally metacognition has been theorised, methodologically studied and empirically tested from the standpoint mainly of individuals and their learning contexts. In this dissertation the emergence of metacognition is analysed more broadly. The aim of the dissertation was to explore socially shared metacognitive regulation (SSMR) as part of collaborative learning processes taking place in student dyads and small learning groups. The specific aims were to extend the concept of individual metacognition to SSMR, to develop methods to capture and analyse SSMR and to validate the usefulness of the concept of SSMR in two different learning contexts; in face-to-face student dyads solving mathematical word problems and also in small groups taking part in inquiry-based science learning in an asynchronous computer-supported collaborative learning (CSCL) environment. This dissertation is comprised of four studies. In Study I, the main aim was to explore if and how metacognition emerges during problem solving in student dyads and then to develop a method for analysing the social level of awareness, monitoring, and regulatory processes emerging during the problem solving. Two dyads comprised of 10-year-old students who were high-achieving especially in mathematical word problem solving and reading comprehension were involved in the study. An in-depth case analysis was conducted. Data consisted of over 16 (30–45 minutes) videotaped and transcribed face-to-face sessions. The dyads solved altogether 151 mathematical word problems of different difficulty levels in a game-format learning environment. The interaction flowchart was used in the analysis to uncover socially shared metacognition. Interviews (also stimulated recall interviews) were conducted in order to obtain further information about socially shared metacognition. The findings showed the emergence of metacognition in a collaborative learning context in a way that cannot solely be explained by individual conception. The concept of socially-shared metacognition (SSMR) was proposed. The results highlighted the emergence of socially shared metacognition specifically in problems where dyads encountered challenges. Small verbal and nonverbal signals between students also triggered the emergence of socially shared metacognition. Additionally, one dyad implemented a system whereby they shared metacognitive regulation based on their strengths in learning. Overall, the findings suggested that in order to discover patterns of socially shared metacognition, it is important to investigate metacognition over time. However, it was concluded that more research on socially shared metacognition, from larger data sets, is needed. These findings formed the basis of the second study. In Study II, the specific aim was to investigate whether socially shared metacognition can be reliably identified from a large dataset of collaborative face-to-face mathematical word problem solving sessions by student dyads. We specifically examined different difficulty levels of tasks as well as the function and focus of socially shared metacognition. Furthermore, the presence of observable metacognitive experiences at the beginning of socially shared metacognition was explored. Four dyads participated in the study. Each dyad was comprised of high-achieving 10-year-old students, ranked in the top 11% of their fourth grade peers (n=393). Dyads were from the same data set as in Study I. The dyads worked face-to-face in a computer-supported, game-format learning environment. Problem-solving processes for 251 tasks at three difficulty levels taking place during 56 (30–45 minutes) lessons were video-taped and analysed. Baseline data for this study were 14 675 turns of transcribed verbal and nonverbal behaviours observed in four study dyads. The micro-level analysis illustrated how participants moved between different channels of communication (individual and interpersonal). The unit of analysis was a set of turns, referred to as an ‘episode’. The results indicated that socially shared metacognition and its function and focus, as well as the appearance of metacognitive experiences can be defined in a reliable way from a larger data set by independent coders. A comparison of the different difficulty levels of the problems suggested that in order to trigger socially shared metacognition in small groups, the problems should be more difficult, as opposed to moderately difficult or easy. Although socially shared metacognition was found in collaborative face-to-face problem solving among high-achieving student dyads, more research is needed in different contexts. This consideration created the basis of the research on socially shared metacognition in Studies III and IV. In Study III, the aim was to expand the research on SSMR from face-to-face mathematical problem solving in student dyads to inquiry-based science learning among small groups in an asynchronous computer-supported collaborative learning (CSCL) environment. The specific aims were to investigate SSMR’s evolvement and functions in a CSCL environment and to explore how SSMR emerges at different phases of the inquiry process. Finally, individual student participation in SSMR during the process was studied. An in-depth explanatory case study of one small group of four girls aged 12 years was carried out. The girls attended a class that has an entrance examination and conducts a language-enriched curriculum. The small group solved complex science problems in an asynchronous CSCL environment, participating in research-like processes of inquiry during 22 lessons (á 45–minute). Students’ network discussion were recorded in written notes (N=640) which were used as study data. A set of notes, referred to here as a ‘thread’, was used as the unit of analysis. The inter-coder agreement was regarded as substantial. The results indicated that SSMR emerges in a small group’s asynchronous CSCL inquiry process in the science domain. Hence, the results of Study III were in line with the previous Study I and Study II and revealed that metacognition cannot be reduced to the individual level alone. The findings also confirm that SSMR should be examined as a process, since SSMR can evolve during different phases and that different SSMR threads overlapped and intertwined. Although the classification of SSMR’s functions was applicable in the context of CSCL in a small group, the dominant function was different in the asynchronous CSCL inquiry in the small group in a science activity than in mathematical word problem solving among student dyads (Study II). Further, the use of different analytical methods provided complementary findings about students’ participation in SSMR. The findings suggest that it is not enough to code just a single written note or simply to examine who has the largest number of notes in the SSMR thread but also to examine the connections between the notes. As the findings of the present study are based on an in-depth analysis of a single small group, further cases were examined in Study IV, as well as looking at the SSMR’s focus, which was also studied in a face-to-face context. In Study IV, the general aim was to investigate the emergence of SSMR with a larger data set from an asynchronous CSCL inquiry process in small student groups carrying out science activities. The specific aims were to study the emergence of SSMR in the different phases of the process, students’ participation in SSMR, and the relation of SSMR’s focus to the quality of outcomes, which was not explored in previous studies. The participants were 12-year-old students from the same class as in Study III. Five small groups consisting of four students and one of five students (N=25) were involved in the study. The small groups solved ill-defined science problems in an asynchronous CSCL environment, participating in research-like processes of inquiry over a total period of 22 hours. Written notes (N=4088) detailed the network discussions of the small groups and these constituted the study data. With these notes, SSMR threads were explored. As in Study III, the thread was used as the unit of analysis. In total, 332 notes were classified as forming 41 SSMR threads. Inter-coder agreement was assessed by three coders in the different phases of the analysis and found to be reliable. Multiple methods of analysis were used. Results showed that SSMR emerged in all the asynchronous CSCL inquiry processes in the small groups. However, the findings did not reveal any significantly changing trend in the emergence of SSMR during the process. As a main trend, the number of notes included in SSMR threads differed significantly in different phases of the process and small groups differed from each other. Although student participation was seen as highly dispersed between the students, there were differences between students and small groups. Furthermore, the findings indicated that the amount of SSMR during the process or participation structure did not explain the differences in the quality of outcomes for the groups. Rather, when SSMRs were focused on understanding and procedural matters, it was associated with achieving high quality learning outcomes. In turn, when SSMRs were focused on incidental and procedural matters, it was associated with low level learning outcomes. Hence, the findings imply that the focus of any emerging SSMR is crucial to the quality of the learning outcomes. Moreover, the findings encourage the use of multiple research methods for studying SSMR. In total, the four studies convincingly indicate that a phenomenon of socially shared metacognitive regulation also exists. This means that it was possible to define the concept of SSMR theoretically, to investigate it methodologically and to validate it empirically in two different learning contexts across dyads and small groups. In-depth micro-level case analysis in Studies I and III showed the possibility to capture and analyse in detail SSMR during the collaborative process, while in Studies II and IV, the analysis validated the emergence of SSMR in larger data sets. Hence, validation was tested both between two environments and within the same environments with further cases. As a part of this dissertation, SSMR’s detailed functions and foci were revealed. Moreover, the findings showed the important role of observable metacognitive experiences as the starting point of SSMRs. It was apparent that problems dealt with by the groups should be rather difficult if SSMR is to be made clearly visible. Further, individual students’ participation was found to differ between students and groups. The multiple research methods employed revealed supplementary findings regarding SSMR. Finally, when SSMR was focused on understanding and procedural matters, this was seen to lead to higher quality learning outcomes. Socially shared metacognition regulation should therefore be taken into consideration in students’ collaborative learning at school similarly to how an individual’s metacognition is taken into account in individual learning.