Partindo de trabalhos recentes que analisaram os discursos de psicanalistas contemporâneos sobre seu fazer e que se orientaram segundo o método da Análise Institucional do Discurso (AID), pudemos afirmar que a teoria informa o fazer clínico da psicanálise. Isso implicou dizer também que, por via inversa, é a clínica que materializa a teoria. Dessas duas afirmações levantamos uma pergunta: como Freud formula um conceito específico dessa teoria que informa a escuta e o pensamento desses psicanalistas? Escolhemos o conceito de inconsciente, pois ele é, ao que tudo indica, o carro-chefe da metapsicologia freudiana. Assim, analisamos o texto O inconsciente de Freud pelo método da AID. Nossos resultados foram, de certa forma, surpreendentes. No que diz respeito ao lugar constituído pelo e para o conceito, verificou-se, por um lado, que o texto de Freud é um jogo constante entre mostrar o inconsciente, descobri-lo, revelá-lo, caracterizá-lo (como se o inconsciente fosse um fato, um dado da experiência), e entre demonstrá-lo, inferi-lo, hipotetizá-lo, derivá-lo (de modo teórico). Por outro lado, também pudemos verificar que o conceito de inconsciente constrói-se como em bloco, ou melhor, como um caleidoscópio; como se outros conceitos fossem exigidos para dele dar conta. No que se refere ao modo como Freud produz conhecimento, nossas análises apontaram para um modo de enunciação que coloca o inconsciente no contra: contra a filosofia, contra a medicina e contra uma psicologia da consciência. Esse estar no contra é o que, para Freud, insere, incrivelmente, a psicanálise na ordem do discurso da ciência. Ainda no que concerne aos modos de produção de verdade, a metapsicologia parece se sustentar sobre um determinado disposto institucional, que nomeamos como análise. Seria esse dispositivo, segundo nossa pesquisa, que efetua o passe de mágica pelo qual a teoria ganha ares de uma verdade. Por fim, discutimos duas questões: a primeira é relativa ao dispositivo analítico como o definidor da psicanálise, e não necessariamente a metapsicologia. A segunda, à proposta de Guirado para uma clínica ao arrepio da metapsicologia / Based on recent studies that analyzed the discourse of contemporary psychoanalysts, we could state that the theory informs the psychoanalysis clinical work; or, in a reverse way, we could state that the clinic becomes the theory real. These two statements raise a question about how Freud built a specific concept of psychoanalytical theory and the relationship between theory formulation and clinic or the analytical interpretation. The concept of unconscious, considerer the flagship of Freudian metapsychology, was analyzed supported by Institutional Analysis of Discourse method, as it is presented at \"The Unconscious\" by Freud. The results were surprising. From the question which organized the research to the analytical procedures our studies was guided by IAD. Our analysis indicated that, about the place was built for and by the concept, it has been found, first , the Freuds text has shown constant play between discovering unconscious, developing it, characterizing it (as the unconscious were a fact, a fact of experience), and between demonstrating it, inferring it, hypothesizing it, deriving it ( in theoretical mode). Moreover, it has been found that the unconscious concept was constructed as a block, or rather like a kaleidoscope; as if other concepts were required to explain unconscious itself. Relating to the way Freud produces knowledge, our analysis indicated that the unconscious is placed \"against\"; against philosophy, against medicine and against a psychology of consciousness. This \"being against\" is what inserts, incredibly, psychoanalysis in science discourse order, for Freud. Even with regard to knowledge production modes, metapsychology seems to stand on a certain institutional dispositive, which we name as \"analysis\". According to our research, this dispositive is the one that makes the \"magic\" in which theory gains airs of truth. Finally, we have discussed two issues, first, the analytical dispositive, not necessarily the metapsychology, as the definer of psychoanalysis; second, Guirados proposition of a clinic out of metapsychology

Este trabalho apresenta um relato e uma reflexão sobre uma clínica psicanalítica realizada fora do setting analítico tradicional, em uma instituição pública da Assistência Social. Esta prática clínica vem sendo desenvolvida em um projeto municipal de apoio sócio educativo aberto, destinado a atender crianças e adolescentes consideradas, pelo Estatuto da Criança e do Adolescente, em situação de risco pessoal e social por estarem expostas a situações de riscos com conseqüências prejudiciais ao seu pleno desenvolvimento em múltiplas dimensões. Nesta instituição são realizados grupos-oficina com as crianças possibilitando um espaço de escuta analítica para a expressão do modo como estas incluem o significante situação de risco, em suas existências particulares. Parte-se da hipótese de que este significante, por ser um imperativo social, produz um efeito de “aprisionamento” em uma única forma de subjetivação, impedindo-as de uma singularização da subjetividade. O objetivo do presente trabalho é, a partir desta prática, delinear uma clínica psicanalítica ampliada no referencial lacaniano da teoria dos quatros discursos. Os grupos-oficina, compreendidos como uma estrutura discursiva, visam possibilitar a construção de laços sociais coletivos através do dispositivo do Discurso do Analista. Nesta clínica o coordenador do grupo deve operar procurando situar-se no lugar do agente do Discurso do Analista a fim de provocar a produção de novos sentidos para o significante situação de risco a que estas crianças estão submetidas e possibilitar que a criança aproprie-se de significantes mestre (S1) e agencie seus discursos. / This study presents a reflection on a carried through psychoanalytical clinic of setting analytical traditional, in a public institution of the Social Assistance. This practical clinic comes being developed in a municipal project of support opened educative partner, destined to take care of to children and considered adolescents, for the Statute of the Child and the Adolescent, in situation of personal and social risk for being displayed the situations of risks with harmful consequences to its full development in multiple dimensions. Hypotheses initial is of that this significant one, for being a social imperative, produces an effect of "capture" in an only form of to become subjective, hindering them subjectivity. The objective of the present work is to delineate an extended psychoanalytic clinic in the Lacan referential of the theory of the four speeches. The group-workshop, understood as a speech structure, aims at to make possible the construction of collective social bows through the device of the Speech of the Analyst. In this clinic the coordinator of the group must operate looking for to place itself in the place of the agent of the Speech of the Analyst in order to provoke the production of new sensible for the significant situation of risk the one that these children are submitted and to make possible that the significant child assumes itself of master (S1) and articulate its speeches.

Esta tese tem como perspectiva a hipótese segundo a qual os conceitos de Eu-Pele e de Envelopes Psíquicos, desenvolvidos pelo psicanalista Didier Anzieu, permitem um viés importante na compreensão da questão da constituição dos limites e fronteiras psíquicos, nas patologias da anorexia e da bulimia na clínica psicanalítica. Tomando como eixo principal na abordagem desses quadros patológicos o tema dos limites - eu/outro, dentro/fora, corpo/psique, são discutidas as concepções dos autores Brusset, Jeammet e McDougall, referentes às condições necessárias para o estabelecimento dos limites nessas patologias alimentares. É realizado um percurso pela obra de Didier Anzieu de tal forma a permitir, a partir dos conceitos de eu-pele e envelopes psíquicos, a compreensão da teorização do autor acerca dos limites e fronteiras, que serão, posteriormente, articulados a sua presença na anorexia e na bulimia. Por fim, é possível afirmar que falhas nas funções e constituição do eu-pele e dos envelopes psíquicos, acarretam um sério comprometimento na constituição dos limites do psiquismo nas patologias alimentares da anorexia e da bulimia / This thesis is based on the perspective that the concepts of skin-ego and psychic envelope, developed by the psychoanalyst Didier Anzieu, bring an important contribution for the comprehension of the problematic of the constitution of psychic limits and boundaries in the disorders of anorexia and bulimia in the psychoanalytic clinic. Taking this as the main theoretical framework for the understanding of these pathological frames, the question of the limits - I/other, inside/outside, body/psyche - is discussed based on contributions from Brusset, Jeammet and McDougall, concerning the necessary conditions for the establishment of the limits within these pathologies. It is undertaken, therefore, a reading of the work of Didier Anzieu, in a way to allow, from the concepts of skin-ego and psychic envelope, the comprehension of the proposition of the author on the limits and boundaries for the articulation with anorexia and bulimia. Finally, we argue that the lack in the function and constitution of the skin-ego and psychic envelope, brings serious consequences to the constitution of the psychic limits in the eating disorders of anorexia and bulimia

A proposta do presente trabalho foi examinar as incidências do educar no tratar para pensar os desafios de uma clínica psicanalítica da psicose infantil e do autismo. Muitos trabalhos vêm discutindo as contribuições da psicanálise para a educação, ou seja, as incidências do tratar no educar; nossa proposta aponta em outra direção, ou seja, propusemo-nos a pensar as muitas incidências do educar no tratar. Buscamos perseguir a presença do educativo no tratamento, de modo a fazer ressaltar sua dimensão terapêutica na clínica da psicose infantil e do autismo, apontando então para uma clínica ampliada, na qual a educação tem uma especial participação. Elegemos três eixos temáticos a serem percorridos para dar sustentação às nossas proposições, a saber: as incidências do educar no tratar, a clínica psicanalítica da psicose infantil e do autismo, o trabalho de Educação Terapêutica com a escrita. Ao examinarmos as incidências do educar sobre o tratar, encontramos diferentes sentidos para o ato educativo que, ao ser aplicado no tratamento de crianças psicóticas e autistas terão, como consequência, diferentes direções de tratamento. Com o médicopedagogo Jean Itard temos a incidência do educativo no nascimento do tratamento psiquiátrico da criança: encontramos aí uma reeducação. Outros sentidos do educar foram localizados e discutidos. Apresentamos a primeira educação que teria como princípio introduzir o bebê humano no campo da linguagem, a educação do inacabado que, em certa medida, também está referida à primeira educação, pois assinala o campo de cuidados com a primeira infância que promove a constituição psíquica e a educação como transmissão de marcas da cultura, e aqui se incluem as práticas escolares e a aquisição da escrita. O exame da clínica psicanalítica com crianças psicóticas e autistas levou-nos à abordagem do autismo e da psicose infantil como efeito dos entraves dessa educação fundamental ou primeira educação. Como pensar, então, a incidência do educar no tratamento das crianças psicóticas e autistas? Abrimos caminho, então, para pensar uma clínica psicanalítica na qual educar e tratar estariam colocados em uma relação de continuidade, indicando que a psicanálise e a educação não estariam em campos disjuntos. Nosso trabalho examinou o dispositivo da Educação Terapêutica como um conjunto de práticas de tratamento institucional que aposta em um tipo de intervenção que inclui as práticas educacionais pela via do trabalho com a escrita e marca um campo de trabalho na clínica psicanalítica ampliada em que o tratar e o educar podem ser pensados como em uma banda de Moebius, na qual o avesso e o direito apresentam uma continuidade e não uma relação de oposição / The purpose of this study was to examine incidences of the education on the treating in addressing the challenges to think of a psychoanalytic clinic of childhood psychosis and autism. Many works have been discussing the contributions of psychoanalysis to education, or the incidences of treating in educating; our proposal points in another direction, ie, we decided to consider the many implications of educating in the treatment. We seek to pursue education in the presence of the treatment so as to indicate its size in the clinical treatment of childhood psychosis and autism, then pointing to an extended clinic, in which education has a special participation. We chose three topics to be covered to give support to our propositions, namely: the incidences of educating in the treatment, the psychoanalytic clinic of childhood psychosis and autism, the work of Therapeutic Education through writing. In examining incidences of education on the case, we find different ways to the educational act which, when applied in the treatment of psychotic and autistic children have, as a consequence, different directions of treatment. With the physician-educator Jean Itard have the impact of education in birth of the child psychiatric treatment: a reeducation find there. Other meanings of education were found and discussed. Here is the first education that would introduce the first human baby in the field of language, education unfinished, to some extent, is also referred to his education, because it shows the field of early childhood care that promotes the psychic and education as transmission of crop marks, and here we include school practices and the acquisition of writing. The examination of the psychoanalytic treatment of psychotic and autistic children led us to approach to autism and childhood psychosis as an effect of the barriers that elementary education or early education. How to think, then, the incidence of educating in the treatment of psychotic and autistic children? We have opened the way, then, to think a psychoanalytic clinic in which to educate and treat would be placed in a relation of continuity, indicating that psychoanalysis and education fields would not be disjoint. Our study examined the device of Therapeutic Education as a set of treatment practices in an institutional commitment that type of intervention that includes educational practices through the work with writing and marks a labor camp in the psychoanalytic magnified when treating and education can be thought of as in a Möbius strip, in which the law inside out and have a continuity and not an adversarial relationship

Os contraceptivos de progestagênios isolados, como o implante de etonogestrel, representam uma opção para uso no puerpério. Classicamente, recomenda-se seu uso, a partir da sexta semana após o parto, mas sabe-se que para um grupo de pacientes de risco para curtos intervalos intergestacionais (com baixa adesão ou pouco acesso às orientações contraceptivas neste período), os mesmos podem ser prescritos no puerpério imediato. Porém, mais estudos são necessários para avaliar a segurança materna e neonatal/infantil do implante de etonogestrel (ETG), quando inserido no puerpério imediato. O objetivo do presente estudo foi avaliar dados de segurança materna (clínicos e metabólicos) e neonatal (clínicos) do uso do implante de ETG no puerpério imediato, durante as primeiras 12 semanas após o parto. Foram randomizadas 40 pacientes, entre 18-35 anos, no Ambulatório de Pré-Natal de Baixo Risco do HCFMRP-USP, para dois grupos: 20 para uso doimplante liberador de etonogestrel (ETG), inserido 24-48 horas após o parto; e 20 para uso de 150 mg de acetato de medroxiprogesterona de depósito (AMP-D), a partir da 6ª semana de puerpério (grupo de controle). Os parâmetros clínicos avaliados foram: pressão arterial (PA), peso materno e neonatal, índice de massa corpórea (IMC), circunferência abdominal (CA) e taxa de manutenção de lactação até a 12ª segunda semanade puerpério. Os parâmetros laboratoriais avaliados foram: marcadores hepáticos (lesão e colestase): fosfatase alcalina (FA), gama-GT (?-GT), transaminase glutâmico-pirúvica (TGP),transaminase glutamínica oxalicética (TGO), bilirrubinas totais (BT), bilirrubina direta (BD), bilirrubina indireta (BI), albumina; marcadores inflamatórios: interleucina (IL)-6, fator de necrose tumoral alfa (TNF-?), proteína C reativa (PCR); lipidograma; hemograma e glicemia. As pacientes apresentavam características clínicase laboratoriais basais semelhantes. Observou-se redução do PA, triglicérides, LDL-colesterol, PCR, FA e elevação do peso dos recém-nascidos, da hemoglobina, plaquetas (mais pronunciada no grupo ETG) glicemia, TGP, BT, BD (mais pronunciada no grupo ETG), BI, albumina e durante as primeiras 12 semanas, em ambos os grupos, sem diferença entre eles. No entanto, o peso, IMC e CA reduziram-se mais no grupo ETG do que no grupo de controle entre o basal e a 6 a semana após o parto (ETG: - 4,64 ± 2,71Kg vs. controle: - 2,60 ± 2,45Kg, p=0,017; ETG: - 1,77 ± 1,06Kg/m 2 vs. controle: - 0,97 ± 0,95Kg/m 2 , p=0,026; ETG: -15,30 ± 6,72cm vs.controle: - 9,05 ± 5,84cm, p=0,003; respectivamente); os níveis de leucócitos apresentaram um aumento entre seis e 12 semanas no grupo de controle (ETG: - 440 ± 113céls/µL vs. controle: + 254 ± 377céls/µL, p= 0,005), com declínio entre o período basal e 12 semanas, semelhante em ambos os grupos; o nível de IL-6, apesar de declinar em ambos os grupos, apresentou variação estatisticamente maior entre o basal e 12 semanas no grupo ETG (ETG: -14,30 ± 20,33pg/mL vs.controle: - 6,09 ± 7,23pg/mL, p=0,035); os níveis de TNF-?elevaram-se apenas no grupo de controle, após seis semanas do uso de AMP-D (ETG: - 0,55 ± 2,46pg/mL vs. controle: + 2,21 ± 3,18pg/mL, p=0,001); os níveis de CT e HDL declinaram nos dois grupos com maior queda no grupo de controle, entre seis e 12 semanas pós-parto (ETG: - 7,4 ± 15,01mg/dL vs.controle: - 28,55 ± 17,71mg/dL, p=0,001; ETG: - 0,15 ± 5,02mg/dL vs.controle: - 12,45 ± 7,32mg/dL, p<0,0001; respectivamente); os valores da TGO reduziram mais no grupo de controle em relação ao grupo ETG na variação entre basal e 12 semanas pós-parto (ETG: - 0,40 ± 9,36U/L vs. controle: - 6,05 ± 8,07U/L, p=0,048). Todos os valores estavam dentro dos limites de normalidade para a faixa etária estudada. As demais variáveis e a taxa de manutenção da lactação exclusiva não diferiram entre os grupos. Podemos concluir que a inserção do implante liberador de ETG no pós-parto imediato não foi associada a efeitos clínicos deletérios maternos ou neonatais, nem a alterações laboratoriais maternas significativas. / Progestogen-only contraceptives like the etonogestrel (ETG) implant represent an option for use during the postpartum period. Its use isclassically recommended after the sixth postpartum week, but for patients at risk for short intergestational intervals (with low compliance or with little access to contraceptive guidelines during this period) these contraceptives can be prescribed during the immediate puerperium. However, further studies are needed to assess the maternal and neonatal/infantile safety of this device when inserted during the immediate puerperium. The objective ofthe present study was to assess maternal (clinical and metabolic) and neonatal (clinical) safety data regarding the use of the ETG implant during the immediate postpartum period and the first 12 postpartum weeks. Forty patients aged 18-35 years attended at the Low Risk Prenatal Care Program of HCFMRP-USP were randomly assigned to two groups: 20 subjects use of the ETG-releasing implant inserted 24-48 hours after delivery, and 20 for use of 150 mg depot medroxyprogesterone acetate (DMPA) starting during the 6 th week postpartum (control). The following clinical parameters were assessed: arterial pressure (AP), maternal and neonatal weight, body mass index (BMI), abdominal circumference (AC); liver markers: alkaline phosphatase, gamma glutamyl transferase (?-GT), glutamic pyruvic transaminase (GPT), glutamic oxaloacetic transaminase (GOT), total bilirubins (TB), direct bilirubin (DB), indirect bilirubin (IB), albumin; inflammatory markers: interleukin-6 (IL)-6, tumor necrosis factor alpha (TNF-?), C reactive protein (CRP); lipid profile; blood count; glycemia, and rate of breastfeeding mothers up to the 12 th week of the puerperium. The basal clinicaland laboratory characteristics of the two groups were similar. We observed a reduction of AP, triglycerides, LDL-cholesterol, CRP and alkaline phosphatase, and an increase in newborn weight, hemoglobin, platelets (more pronounced in the ETG group), glycemia, GPT,TB,DB (more pronounced in the ETG group), IB and albumin during the first 12 weeks in both groups, with no difference between them. However, weight, BMI and AC were lower in the EGT group compared to control up to the 6th week after delivery (ETG: - 4.64 ± 2.71Kg vs. control: - 2.60 ± 2.45Kg, p=0.017; ETG: - 1.77 ± 1.06Kg/m 2 vs. control: - 0.97 ± 0.95Kg/m 2 , p=0.026; ETG: -15.30 ± 6.72cm vs. control: - 9.05 ± 5.84cm, p=0.003; respectively); white cell count increased between six and 12 weeks after delivery in control group (ETG: - 440 ± 113céls/µL vs. control: + 254 ± 377céls/µL, p= 0.005), with a decrease between basal evaluation and 12 weeks after delivery in both groups; IL-6 decrease in both groups however the variation was statistically different between basal and 12 weeks only in ETG group (ETG: -14.30 ± 20.33pg/mL vs.control: - 6.09 ± 7.23pg/mL, p=0.035); TNF-?levels was higher only in the control group six weeks after DMPA administration (ETG: - 0.55 ± 2.46pg/mL vs. control: + 2.21 ± 3.18pg/mL, p=0.001); HDL levels decrease in both groups however it was more pronounced in control group between six and 12 weeks postpartum (ETG: - 7.4 ± 15.01mg/dL vs.control: - 28.55 ± 17.71mg/dL, p=0.001; ETG: - 0.15 ± 5.02mg/dL vs.control: - 12.45 ± 7.32mg/dL, p<0.0001; respectively); TGO levels was lower in control group than in ETG between basal evaluation and 12 weeks postpartum (ETG: - 0.40 ± 9.36U/L vs. control: - 6.05 ± 8.07U/L, p=0.048). All values were within normal limits for the age range studied. The other variables and the maintenance of exclusive lactation were similar between the groups. In conclusion, ETG releasing implant insertion during the immediate postpartum period was not associated with deleterious maternal or neonatal clinical effects or with significant laboratory alterations.

A l’intersection de plusieurs champs disciplinaires – littérature, philosophie, histoire, épistémologie médicale, psychanalyse, droit -, ce travail reconstruit le cheminement de l’auteur qui, après de nombreuses publications [romans, essais, articles], expose les expériences, les connaissances et les outils conceptuels qui lui ont permis d’interpréter la répétition génocidaire dans les Balkans et de s’engager dans le débat éthique en médecine. Parvenue dans ses ouvrages précédents à un résultat qu’elle estime à la fois scientifique – d’un point de vue clinique – et éthique, un résultat qui lui permet, à partir de la mise en évidence du mécanisme clinique de la répétition, d’énoncer une loi vérifiable dans les Balkans, elle rend compte de sa démarche pour en venir à interroger le bain de langage actuel et la responsabilité de l’écrivain, mais aussi des historiens et de la critique, face à la spécificité génocidaire qui occupe, ici, la place d’un réel par la plupart impensé. Cette étape d’un travail en cours permet de comprendre que si la littérature permet de révéler ce qu’il en est du réel en tant qu’il est humain, le réel n’est pas synonyme de vérité. En revanche, la mise en évidence d’un mécanisme réel – un mécanisme qu’il faut qualifier ici de psycho-historique ou mémoriel – permet d’approcher avec plus de précision la situation actuelle, de mieux en saisir la logique, et d’envisager de nouvelles stratégies pour tenter de contribuer à construire la paix dans les Balkans, pour les générations futures. / At the intersection of several disciplinary fields – literature, philosophy, history, medical epistemology, psychoanalysis, and law – this work reconstructs the winding path of the author who, after numerous publications [novels, essays, articles], here exhibits the experiences, the knowledge and the conceptual tools that have allowed her to interpret the genocidal repetition in the Balkans, and to become engaged in the ethical debate in medicine. Having reached in her previous works a result that she deems both scientific – from a clinical point of view – and ethical, a result that allows her on the basis of the investigation of the clinical mechanism of repetition to voice a law that can be confirmed in the Balkans, she gives an account of her undertaking so as to interrogate the current language being used and the responsibility, not only of the writer, but also of historians and criticism, faced with the genocidal specificity that here occupies the place of a real that for the most part has not been thought through elsewhere. This stage of a work in progress enables one to understand that if literature allows for the uncovering of the real that is in play in so far as it is human, the real is not synonymous with truth. On the other hand, the investigation of a real mechanism – a mechanism that here has to be qualified as psycho-historic or memorial – allows one to approach the current situation with greater precision, to better grasp its logic, and to envisage new strategies to try and contribute to the construction of peace in the Balkans, for future generations.

The understanding of how white blood cells react when coming into contact with various surfaces is of major importance for a wide range of biomaterials and biosensor applications. In this study it is investigated if it is possible to determine how neutrophils react to a certain type of sensor chip called cell clinic being developed. This study investigates the cell surface coverage on the sensor chip and how it correlates to the signal response of the sensor at hand. Neutrophils, as other white blood cells, are cells that quickly adhere to surfaces and during the adhesion process they activate at different levels depending on i.e. type of surface or surface functionalization, this activation can be visualized by the change in morphology. While measuring the change of capacitance with the cell clinic sensor during cell adhesion, the cell surface coverage is of main importance. The main focus of this diploma work has been to develop an image analysis script capable of conducting automated analysis on a large body of images estimating the surface coverage. Input data for this modeling is taken from fluorescent microscopy images. The experiments conducted during this project have indicated that white blood cells adhered to the sensor surface shows signs of being activated also without external activation. This clearly shows that knowledge of how neutrophils react to surface modifications is of great importance as well as the awareness that any surface may trigger a response from the immune system i.e. neutrophil activation, so also in the cell clinic. It is a fact that it might be difficult to evaluate the effect of a foreign substance on the neutrophils while a significant amount is activated from being in contact with the surface. Regarding different surfaces the white blood cells does not display any preference of adhering to any specific surface. The surfaces used in this project was silicon oxide wafers, silicon oxide wafers with a nitride surface functionalization and the intended sensor chip; however the addition of PMA clearly shows an effect on how many cells that adheres to the surface as well as the average area of each cell.

[pt] O objetivo principal de nosso estudo foi o de promover uma reflexão sobre os atendimentos psicanalíticos desenvolvidos nos ambulatórios hospitalares. Partimos do princípio que a dinâmica hospitalar (re)produz a interpenetração público/privado característica da atualidade. Assim, pensar as relações entre o público, o privado e a psicanálise perpassa a construção da tese como um todo. Analisou-se as relações entre o público e o privado na antiguidade grega, no transcorrer do século XIX e na atualidade. Dessa análise, promoveu-se uma correspondência entre os modos de relação estabelecidos entre público e privado no século XIX e a clínica particular, assim como público/privado na atualidade e a clínica ambulatorial. Para especificar os elementos organizadores da clínica ambulatorial, cinco psicanalistas foram entrevistados. A análise das entrevistas nos permitiu destacar, como características principais do campo clínico ambulatorial, a visibilidade extrema, a transitoriedade e o campo transferencial complexo estruturado a partir de elementos subjetivos e ambientais. A perspectiva da clínica winnicottiana foi tomada como alternativa possível na condução desses processos analíticos, na medida em que esta nos permite propor um trabalho transformador no qual o paciente encontra possibilidades de agir, de uma forma criativa, tanto sobre a realidade subjetiva quanto sobre o mundo que o cerca. / [en] The primary purpose of this thesis is to analyze the psychoanalytic clinics, which exist in general hospitals. It is the author`s hypothesis that the close interpenetration between the public and the private spheres is reflected in such practice and determinant as far as the difficulties and obstacles are concerned. The relationships between the public and the private spheres from the Greek antiquity, to the present time are analyzed pointing out the correspondence between the increase of privacy and the birth of the psychoanalytical private clinic. To classify the organizing elements of such clinic five psychoanalysts were interviewed. The analysis of the interviews allowed to highlight, as main characteristics of the field, the high visibility, transitiveness and the complex transference field, which emerges from subjective and environmental elements. Winnicott`s theoretical framework was suggested as a possible alternative for a creative and effective clinic in such environments.

Background: Immunological and virological responses to ART are important outcome indicators that are mostly used to evaluate the success of an ART program. A comparative performance between ART providers based on the two outcomes can be useful in optimising resources to underperforming providers and advising quality improvement plans. Aim: To compare immunological and virological responses of ART for adult HIV positive patients between providers in Tshwane District, Gauteng Province, South Africa. Methodology: This study was an analytical observational study that retrospectively compared patient treatment outcomes on immunological and virological responses between 16 Antiretroviral Therapy (ART) providers. The analysis compared baseline patients’ status on these two outcomes with their statuses after 6 and12 months on ART. Ordinary logistic regression was used to calculate Standardised Incidence Ratios (SIR), while multilevel model analysis was used to calculate specific provider random effects of poor immunological and virological responses. Results: After 6 months of treatment, the SIR of poor immunological outcome for all clinics under study, as predicted by the unadjusted logistic regression models was 0.29 (95% CI: 0.27-0.31), but varied from a low of 0.14 (95% CI: 0.00-0.40) to a high of 0.66 (95% CI: 0.13-1.20) between the clinics. Two clinics had a Standardised Incidence Ratio (SIR) of poor immunological response that was significantly below 1 (poor immunological rate below average), while three clinics had an SIR above 1 (poor immunological rate above average) under the unadjusted logistic models. After adjusting for the effects of gender, age, drug combination, religion and present virological status, no clinic had a SIR that was significantly below 1, but two clinics had a SIR that was significantly above 1. xi Under the logistic multilevel (MLLR) analysis, the unadjusted model flagged two clinics whose clinic specific effects were below zero (lower rate of poor immunological outcome below that of the total sample) and one clinic whose clinic specific effect was above zero (higher rate of poor immunological outcome below the total sample rate). The adjusted model showed that no clinic had residual effects that were significantly below or above zero. The confidence intervals for MLLR model were found not to be wider than those of the logistic regression (LR) models particularly for clinics with small sample sizes. A number of clinics changed the relative order of their SIR/random effects after case-mix adjustments under both the LR and MLLR modelling. For poor virological response, both the LRD and MLLR models indicated no clinic specific effects. The predicted poor virological response rate by the case-mix unadjusted LR model was 0.12 (95% CI 0.11 - 0.13). All clinics except one had SIRs that were not significantly different from 1. After adjusting for CD4 count and age, no clinic had an SIR that was significantly different from 1. Conclusions: Case-mix or patients baseline characteristics explained much of the variation in the Standardised Incidence Ratios (SIR) of poor immunological outcome after 6 months of patient treatment, while provider (clinic) specific effects explained much of the variation after 12 months of treatment. After 6 months of treatment, the results also showed that there were significant differences in the SIR between the clinics before case-mix adjustments, but the differences disappeared after case-mix adjustments. This shows that comparison of treatment outcomes between providers (clinics) can be misleading if no proper adjustment are made for confounding factors. Differences in the SIRs for poor virological outcome, after 6 months of patient treatment were no longer significant between clinics after taking account of CD4 count and age. / Dissertation (MSc)--University of Pretoria, 2014. / gm2014 / School of Health Systems and Public Health / unrestricted

[pt] Embora o papel do vanádio no organismo ainda não tenha sido bem definido, sabemos que ele inibe a atividade das ATPases em eritrócitos e células tubulares renais, afetando a função diurética dos rins, o metabolismo de leucócitos e macrófagos, a função do músculo cardíaco, causando efeitos insulina-like em doses farmacológicas. O vanádio é de grande importância para a indústria, é utilizado como catalisador, na produção de vidros e aço. Os trabalhadores em usinas de produção de aço e indústrias que utilizam combustíveis fósseis como fonte de energia, são expostos a quantidades significativas de vanádio, sendo importante o monitoramento dos seus níveis. No presente trabalho foi desenvolvido um método simples e direto para determinação de vanádio em soro usando a espectrometria de absorção atômica em forno de grafite, otimizado por um planejamento composto central. As temperaturas de pirólise e atomização foram de 1240 e 2600 oC, e calibração externa pode ser realizada com soluções de calibração preparadas em HNO3 2,5 % v/v, mostrando-se linear até, pelo menos, 3 ug L(-1). O pré-tratamento da amostra consistiu tão somente de uma diluição (2+1) no mesmo meio, e os limites de detecção e quantificação encontrados foram, respectivamente, 0,3 e 1,0 ug L(-1). A velocidade analítica foi de 8 amostras h-1, para análises em triplicata. Nos estudos de recuperação foram obtidas valores médios de 97,2%; 99,2% e 105,3%, para concentrações de 1, 2 e 3 ug.L(-1), respectivamente. Houve excelente concordância entre os valores encontrados e o certificado na análise de um material de referência certificado. Nos estudos da repetitividade, o maior coeficiente de variação encontrado foi 10,3% na amostra adicionada de 1 ug L(-1). Nos estudos da precisão intermediária, o maior coeficiente de variação foi 5,6% na amostra adicionada de 2 ug L(-1). As incertezas combinadas obtidas foram 1,65x10-1; 2,72x10-1 e 3,72x10-1, para concentrações de 1, 2 e 3 ug L(-1), respectivamente. O tempo de vida do tubo de grafite nas condições otimizadas foi de, aproximadamente, 150 ciclos. O método foi considerado adequado para a determinação rotineira de vanádio em soro em laboratórios clínicos. / [en] Although the role of vanadium in the body has not been yet well defined, it is known that it inhibits the ATPase activity in erythrocytes and renal tubular cells, affecting the diuretic function of the kidneys, the metabolism of leukocytes and macrophages, the function of the heart muscle and causes insulin-like effects in pharmacological doses. Vanadium is of great importance to the industry, and is mostly used as catalyst, and in the production of glass and steel. Workers of the steel industries as well as those in plants that use large amounts of fossil fuels are potentially exposed to large amounts of vanadium, and it is important to monitor their serum levels. In the present study it was developed a simple and direct method for determination of vanadium in serum using graphite furnace atomic absortion spectrometry optimized by a central composite design. External calibration was possible, using calibration solutions prepared in 2 % v/v HNO3. The sample was 2+1 diluted in the same medium and the calibration curve was found linear up to at least 3 ug L(-1). The limits of detection and quantification were respectively 0.3 and 1.0 ug L(-1), in the original sample. Average recoveries were 97.2%, 99.2% and 105.3% for concentrations of 1, 2 and 3 ug L(-1), respectively. Excellent agreement was found between found and certified values in the analysis of a certified reference material. The sample throughput was 8 h-1 (n=3). In the study of repeatability, the largest coefficient of variation was 10.3% in the sample spiked with 1 ug L(-1) of vanadium. In the study of the intermediate precision the higher coefficient of variation was 5.6% in the sample spiked with 2 μg.L-1. The combined uncertainties obtained were 1.65x10-1, 2.72x10-1 and 3.72x10-1, for concentrations of 1, 2 and 3 ug L(-1), respectively. The graphite tube life time in the optimized conditions was 150 cycles, approximately. The method was considered adequate to the routine determination of vanadium in serum in clinical laboratories.