Objetivos: Avaliar e descrever os desfechos maternos e neonatais de gestantes com diagnóstico de cervicodilatação precoce submetidas à cerclagem de emergência ou à conduta expectante com repouso. Avaliar os fatores relacionados com melhores resultados nas gestantes submetidas à cerclagem de emergência. Métodos: Análise retrospectiva de gestantes internadas na Clínica Obstétrica do HCFMUSP, entre 2001 e 2017, com diagnóstico de cervicodilatação precoce e/ou bolsa protrusa. Foram incluídas gestantes com feto único, entre 16 semanas e 25 semanas e 6 dias, com dilatação cervical entre 1 e 3 cm e excluídas gestantes que evoluíram para parto ou aborto em até 2 dias após a internação. Resultados: O estudo envolveu 30 gestantes, 19 no grupo cerclagem e 11 no grupo repouso. Houve diferença significativa entre os grupos para dois dos desfechos primários, com o grupo cerclagem apresentando os melhores resultados: idade gestacional no parto 28,65 versus 23,35 semanas (p=0,031), latência entre a internação e o aborto/parto 48,63 versus 16 dias (p=0,016). Dentro do grupo cerclagem, as gestantes sem bolsa protrusa apresentaram maior idade gestacional no parto: 33,91 versus 26,82 semanas (p=0,032). Na comparação de gestantes com desfecho favorável e desfavorável entre aquelas submetidas à cerclagem, não houve diferença significante para os fatores de risco analisados (antecedentes obstétricos, dilatação cervical, exames laboratoriais ou corioamnionite clínica). Conclusões: A cerclagem de emergência foi superior que à conduta expectante no tratamento de gestantes com cervicodilatação precoce no segundo trimestre da gestação, apresentando melhores resultados gestacionais. Dentre as gestantes submetidas à cerclagem, a ausência de bolsa protrusa esteve relacionada a maior prolongamento da gestação. Não foi possível caracterizar fatores de risco para o sucesso da cerclagem (determinado como taxa de \"bebê em casa\") / Objectives: To evaluate and describe the maternal and neonatal outcomes of pregnant women with early cervical dilatation diagnosis submitted to emergency cerclage or to expectant management with bedrest. To evaluate factors related to better outcomes in pregnants submitted to emergency cerclage. Methods: Retrospective analysis of pregnants hospitalized at the Obstetrics Clinic of HCFMUSP between 2001 and 2017 with diagnosis of early cervical dilatation and/or protruding membranes. Pregnants of singleton gestation between 16 weeks and 25 weeks and 6 days, with cervical dilatation of 1 to 3 cm were included. Those ones who have had delivery or miscarriage within 2 days after admission were excluded. Results: The study involved 30 pregnant women, 19 in the cerclage group and 11 in the rest group. There was a significant difference between groups for 2 of the primary outcomes, with the cerclage group showing the best results: gestational age at delivery 28.65 versus 23.35 weeks (p=0.031), latency between hospitalization and abortion / delivery 48.63 versus 16 days (p=0.016). In cerclage group, pregnants without protruding membranes presented higher gestational age at delivery: 33.91 versus 26.82 weeks (p=0.032). In comparison of patients with favorable and unfavorable outcome between those submitted to cerclage, there was no significant difference for the risk factors analyzed (obstetric history, cervical dilatation, laboratory exams or clinical chorioamnionitis). Conclusions: Emergency cerclage was superior to expectant management in the treatment of pregnants with early cervical dilatation in the second trimester of gestation, with better gestational outcomes. Among the pregnants submitted to cerclage, the absence of a protruding membranes was related to a better prolongation of gestation. It was not possible to characterize risk factors for cerclage success (determined as take-home baby rate)

A presente dissertação configura-se como uma interrogação à teoria psicanalítica acerca das ressonâncias do traumatismo na função psíquica da memória. Ambos são conceitos que remetem aos fundamentos da psicanálise, apontando para a constituição do psiquismo, bem como para seus limites. A dissertação procura ampliar o estudo da temática para além da obra de Freud e alcançar as contribuições de Sandor Ferenczi e seus desdobramentos na obra de Nicolas Abraham e Maria Torok. Em Freud, as relações de trauma e memória, principalmente a partir da conceituação de um além do princípio do prazer, apontam para o funcionamento, ou melhor, às falhas de funcionamento nos limites do psíquico - entre corpo e psique, entre percepção e representação - responsáveis pela instauração da memória e a diferenciação psíquica. O traumático foi associado à dinâmica da pulsão de morte e a da angústia automática, que faz continuamente uma demanda de trabalho psíquico, de ligação, anterior à instauração do princípio de prazer. Quando não há possibilidade de ligação e transcrição do acontecimento, seus efeitos apresentam-se de forma negativa como danos narcísicos. Ferenczi considera o papel do objeto como determinante em relação ao destino traumático de um acontecimento. Caso o objeto não possa adaptar-se às necessidades do sujeito e fornecer ou legitimar um sentido ao vivido, interrompe-se o processo de introjeção e inscrição psíquica. Frente ao desamparo psíquico decorrente da ausência de investimento do objeto, o psiquismo se defende por meio da clivagem das impressões traumáticas ou imerge em comoção, da qual não resta memória. Nicolas Abraham e Maria Torok acrescentam que um acontecimento que permaneceu clivado no psiquismo de uma geração - impossibilitado de circulação e figurabilidade - é transmitido enquanto lacuna de memória para a próxima geração. A imagem do trauma como avesso da memória é paradoxal, pois remete tanto às impressões que aguardam uma revelação por meio de uma ligação com uma imagem, no modelo dos sonhos traumáticos, como à pura negatividade relativa à falta de representação, da qual um sentido pode advir mediante somente uma construção que produza um sentimento de convicção. Tal imagem paradoxal pretende oferecer uma reserva psíquica/teórica ao analista enquanto uma figurabilidade possível das ressonâncias do traumático na memória. / This research was developed in the Nursery Annex to the Maternity of the Central Institute of Hospital das Clínicas of São Paulo. In this service, the situation of prematurity is highlighted, and experienced much more frequently since it is connected to an Obstetric Clinic that serves pregnant women at high risk. In this study, when they approached the situation of prematurity, I am referring to the newborn pre-term extreme, that is those born with gestational age below 30 weeks, whereas the term pregnancy lasts 40 weeks. The pre-term babies the attention of their immaturity and the way they are exposed and being manipulated by various professionals, with few significant contacts that could help them develop. What parents can come closer and touch your child will need assistance to help you understand the situation and find ways to contact us. Faced with the distress that this situation arouses, it is important to understand the possibilities of intervention of the health team. What is happening is that, especially in the first contact, the parents need to make the team any intermediation, as are a number of devices connected to your child and are faced with something completely strange and distant from everything that could have imagined. This study aimed to understand, from the speech of mothers, which the experiences and conflicts they face and how the interventions of the health team are promoting or otherwise, regarding the approach and contact the mother for her son, in different times of hospitalization. This research has a qualitative character, work with individual interviews and consultations conducted with the mother. The intention was to contact the original issues, the positioning of the mother before the intervention team and the whole situation of prematurity, during hospitalization of the infant.

Objetivo: O objetivo desse estudo foi identificar a associação entre fatores clínicos e laboratoriais com o uso de insulina em gestantes com DMG no momento do diagnóstico e analisar os possíveis fatores preditores do uso de insulina. Método: Foram estudadas, de forma retrospectiva, 294 pacientes com diabetes melito gestacional (DMG) diagnosticado por meio do teste de tolerância à glicose oral de 100 gramas (TTGO-100g) entre 24 e 33 semanas completas de gestação, cujo seguimento pré-natal foi realizado ambulatorialmente pelo setor de Endocrinopatias e Gestação da Clínica Obstétrica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de 1 de julho de 2002 a 30 de junho de 2008. Os seguintes fatores clínicos e laboratoriais, que pudessem estar associados ao uso de insulina para controle glicêmico, foram analisados: idade materna, obesidade pré-gestacional - índice de massa corpórea (IMC) > 30 Kg/m2, antecedente familiar de diabetes melito (DM), tabagismo, hipertensão arterial, uso de corticosteróides sistêmicos, antecedente obstétrico de DMG e de macrossomia fetal, nuliparidade, multiparidade, antecedente obstétricos de natimortos e neomortos, idade gestacional no momento do diagnóstico, gemelidade, índice de líquido amniótico (ILA) aumentado ILA > 18 cm, polidrâmnio (ILA > 25 cm), número de valores anormais do TTGO-100g, glicemia de jejum anormal no TTGO- 100g glicemia de jejum > 95 mg/dL; média das quatro glicemias aferidas no TTGO-100g; valor da glicemia de jejum, de 1ª, 2ª e 3ª horas do TTGO-100g e hemoglobina glicada (HbA1c). A associação entre cada fator e a necessidade de insulinoterapia foi analisada individualmente (2 de Pearson / teste exato de Fisher e teste t de Student). O modelo de regressão logística para a análise multivariada foi usado para predizer a probabilidade desses fatores em relação ao uso de insulina. Resultados: Das 294 pacientes avaliadas, 39,8% (117/294) necessitaram de insulinoterapia para controle glicêmico. Observou-se correlação positiva entre o uso de insulina e obesidade pré-gestacional, antecedente familiar de DM, hipertensão arterial, antecedente obstétrico de DMG e de macrossomia fetal, número de valores anormais no TTGO-100g, glicemia de jejum > 95 mg/dL no TTGO-100g; média das quatro glicemias aferidas no TTGO-100g; valor da glicemia de jejum, de 1ª, 2ª e 3ª horas do TTGO-100g e HbA1c pela análise univariada (P<0,05). Na análise do modelo de regressão logística foram desenvolvidos dois modelos que incluíam os seguintes fatores preditores do uso de insulina: obesidade pré-gestacional, antecedente familiar de DM, número de valores anormais no TTGO-100g (só modelo 1) e valor da glicemia de jejum do TTGO-100g (só modelo 2). Os dois primeiros modelos foram novamente analisados, incluindo-se a variável HbA1c para verificação de sua contribuição na predição do uso de insulina. Curvas de probabilidade e escores foram construídos com base nas quatro combinações de fatores preditores. Conclusões: É possível estimar a probabilidade do uso de insulinoterapia para controle glicêmico em gestantes com DMG por meio de IMC pré-gestacional, antecedente familiar de DM, número de valores anormais do TTGO-100g, valor da glicemia de jejum no TTGO-100g e da HbA1c. / Objective: To determine the association between clinical and laboratory parameters and insulin requirement in pregnancies complicated by gestational diabetes mellitus (GDM), and to evaluate possible factors predicting the need for insulin therapy. Methods: A total of 294 patients with GDM diagnosed by the 100- g/3-h oral glucose tolerance test (OGTT) between 24 and 33 complete weeks of gestation were retrospectively studied. These patients were under prenatal follow-up at the Obstetric Clinic of the University of Sao Paulo School of Medicine (HCFMUSP) between July 1, 2002 and June 30, 2008. The clinical and laboratory factors which could be associated to the need for insulin therapy were analyzed: maternal age, prepregnancy obesity body mass index (BMI) > 30 Kg/m2, family history of diabetes mellitus (DM), smoking, hypertension, use of systemic corticosteroids, prior GDM, prior fetal macrosomia, nulliparity, multiparity, prior stillbirth, prior neonatal death, gestational age at diagnosis of GDM, multiple pregnancy, elevated amniotic fluid index (AFI) AFI > 18 cm, polyhydramnios (AFI > 25 cm), number of abnormal 100-g/3-h OGTT values, 100-g/3-h OGTT fasting plasma glucose > 95 mg/dL, mean of the four 100-g/3-h OGTT values, 100-g/3-h OGTT fasting/one/two/three plasma glucose values, and glycated hemoglobin (HbA1c). The association between each factor and the need for insulin therapy was then analyzed individually (Pearsons chi-square/Fishers exact or Student t test). The performance of these factors to predict the probability of insulin therapy was estimated using a logistic regression model. Results: Among the 294 patients studied, 39.8% (117/294) required insulin for glycemic control. Univariate analysis showed a positive correlation between insulin therapy and prepregnancy obesity, family history of diabetes, hypertension, prior GDM, prior fetal macrosomia, number of abnormal 100-g/3-h OGTT values, 100-g/3-h OGTT fasting plasma glucose > 95 mg/dL, mean of the four 100-g/3-h OGTT values, 100-g/3-h OGTT fasting/one/two/three plasma glucose values, and HbA1c (P < 0.05). Two logistic regression models were developed and included the following parameters: prepregnancy obesity, family history of diabetes, number of abnormal 100-g/3-h OGTT values (just model 1) and 100-g/3-h OGTT fasting plasma glucose (just model 2). The two first models were analysed another time including the variable HbA1c to verify its contribution on prediction of the need for insulin therapy. Probability curves and scores were constructed based on the four combinations of predictive factors. Conclusions: The probability of insulin therapy can be estimated in pregnant women with GDM based on prepregnancy obesity, family history of diabetes, number of abnormal 100-g/3-h OGTT values, 100-g/3-h OGTT fasting plasma glucose, and HbA1c concentration.

La présente thèse vise à comprendre les ressorts sociaux de la conversion politique d’un pionnier de la Résistance, le journaliste Emmanuel d’Astier (1900-1969). Issu de l’aristocratie catholique et conservatrice, proche de l’Action française et journaliste bohême auteur d’articles antisémites et antirépublicains dans l’entre-deux-guerres, d’Astier est en 1940 lefondateur d’une des premières organisations de résistance à l’occupation nazie. Á l’avant-garde de l’antivichysme sous l’Occupation, haut dirigeant de la Résistance, d’Astier devient à la Libération député et compagnon de route du Parti communiste. Son engagement dans la Résistance joue un rôle majeur dans sa conversion politique. Pour comprendre la trajectoire d’Emmanuel d’Astier, il convient d’entrer dans la fabrique sociale de l’acteur, c’est-à-dire de décortiquer les mécanismes et processus continus de la construction sociale de sa personne. Dans cette perspective, il s’agit d’abord de considérer le temps long biographique au cours duquel l’individu est socialement façonné par les multiplesexpériences qu’il est amené à vivre. Il s’agit ensuite d’analyser comment le temps court de l’engagement résistant s’articule au temps long de l’expérience biographique. Ainsi, l’un des enjeux de ce travail est de comprendre à la fois les conditions sociales de possibilité et les incidences biographiques de l’engagement contestataire en contexte autoritaire et critique.Articulant sociologie de la socialisation et sociologie de l’action collective, cette thèse interroge in fine les multiples façons dont histoires sociales individuelles et histoires sociales collectives se percutent, et comment les cheminements des trajectoires individuelles dépendent de ces rencontres. / This thesis questions the social causes of the political conversion of a pioneer of Resistance, the journalist Emmanuel d’Astier (1900-1969). Born in a family of the catholic and conservative aristocracy, Emmanuel d’Astier act during the 1930’s as a bohemian journalist and the author of anti-Semitic and anti-republican articles. In 1940, he is the former of one of the first collective organizations whici fight against the Nazi occupation of France. A great opponant of the regime of Vichy during the Second World War, he becomes a deputy and a friend of communism after the Liberation. His activism in the Resistance plays a major role in his political conversion.To understand the social path of Emmanuel d’Astier, we must analyze the mechanisms and the processes of his social construction. First, we must examine the long-term temporality during which the actor is formed by his biographical experiences. Secondly, we must examine how the short-term temporality of activism articulates with the biographical long-termtemporality. We must understand the social conditions and the biographical consequences of high-risk activism.Ultimately, this thesis articulates a sociology of the socialization with a sociology of collective action. It questions the many ways in which individual paths and collective paths meet, and how individual paths stems from these confluences.

Introdução: A atenção durante o ciclo gravídico puerperal é de extrema importância para garantir a saúde materna e infantil, devendo o pré-natal ocorrer prioritariamente na Atenção Primária à Saúde, respeitando-se a realização de no mínimo sete consultas e a captação da gestante o mais precocemente possível, conforme preconizado nas políticas públicas dessa área. Entretanto, muitas vezes, depara-se com situações fora da normalidade obstétrica, em que patologias relacionadas à gestante e/ou ao feto, impõe a referência da assistência para um nível mais complexo de atenção. Nesse momento, frente a ineficácia dos mecanismos de contrarreferência, a Atenção Primária poderá deixar de obter as informações necessárias para o correto acompanhamento dessas mulheres e de seus conceptos. O presente estudo procurou evidenciar como têm ocorrido os mecanismos de referência e contrarreferência das gestantes encaminhadas por Unidades Básicas de Saúde da Zona Norte do município de São Paulo, para uma Maternidade Escola, referência para gestantes de alto risco, nessa mesma região. Objetivo: Investigar limites e potencialidades do sistema de referência e contrarreferência, no acompanhamento de gestantes de alto risco, encaminhadas para a Maternidade Escola Dr. Mário de Moraes Altenfelder Silva, mais conhecida como Maternidade Escola Cachoeirinha. Método: Trata-se de um estudo descritivo, qualitativo, do tipo estudo de caso, tomando como participantes 14 enfermeiros e 9 médicos das UBS Vila Dionísia e Dra. Ilza Hutzler. Além das entrevistas individuais semiestruturadas, realizou-se a caracterização da população estudada. A partir do referencial teórico adotado, emergiram três unidades temáticas: o sistema de saúde; o funcionamento do sistema de referência e contrarreferência e fatores estruturais das Unidades Básicas de Saúde. A análise dos discursos foi realizada empregando-se a técnica de análise de conteúdo de Bardin, tendo sido evidenciadas 7 subunidades temáticas empíricas. Resultados e Discussão: A análise dos dados permitiu a avaliação do sistema de referência e contrarreferência e da observância dos princípios e diretrizes do SUS, com relação ao pré-natal de alto risco, realizado na Maternidade Cachoeirinha. Evidenciou-se que não ocorre a contrarreferência para as UBS, dessa forma, a continuidade da assistência durante o pré-natal de alto risco, no puerpério e para o recém-nascido é prejudicada. Além disso, observou-se que o conhecimento sobre o SUS, por parte dos trabalhadores entrevistados é deficiente e o conteúdo é pouco abordado durante os programas de graduação. Conclusões: Deve haver capacitação para os profissionais da atenção primária e terciária de forma integrada, no que se refere aos princípios e diretrizes do SUS, principalmente no que diz respeito à referência e contrarreferência. Faz-se necessária também, a capacitação de médicos e enfermeiros das UBS em pré-natal. Para esse estudo, que se trata de um Mestrado Profissional, foram elaboradas duas ferramentas, o fluxograma e o formulário de acompanhamento da gestante de alto-risco, para serem utilizados nas trocas de informações dentro da APS e da atenção terciária. O formulário deverá ser preenchido pela Maternidade mensalmente, e posteriormente, por mala direta, enviada às UBS. / Introduction: Attention during the puerperal pregnancy cycle is extremely important to ensure maternal and infant health, prenatal care should occur primarily in Primary Health Care, respecting the minimum amount of seven visits being performed plus receiving the pregnant at the earliest in order to follow the advocated public policies of this area. However, there are usual situations apart from the obstetric normality, in which pathologies related to either the pregnant woman or the fetus, imposes the reference of care to a more complex level of attention. At this moment, due to the ineffectiveness of counter-referral mechanisms, Primary Care may fail to obtain the necessary information for the correct supervision of these women and their infants. The present study sought to highlight how the reference and counter - referral mechanisms of pregnant women referred by Basic Health Units of the North region in Sao Paulo for a Maternity School, a reference for high-risk pregnant women in this same region. Objective: To investigate the limits and potentialities of the referral and counter-referral system to supervise high-risk pregnant women referred to the Mário de Moraes Altenfelder Silva Maternity School, known as the Cachoeirinha Maternity School. Method: This is a descriptive, qualitative, case-study involving 14 nurses and 9 physicians from the UBS Vila Dionísia and UBS Dr. Ilza Hutzler. In addition to the semi-structured individual interviews, the study population was characterized. Based on the theoretical framework adopted, three thematic units emerged: the health system; the functioning of the reference and counter-reference system and structural factors of the Basic Health Units. The discourse analysis was carried out using Bardin content analysis technique, and seven empirical thematic subunits were evidenced. Results and Discussion: The analysis of the data allowed the evaluation of the referral and counter-referral system and compliance with the principles and guidelines of SUS, with regard to the high-risk prenatal care performed at Maternidade Cachoeirinha. It was evidenced that the counter-referral does not occur for the UBS, therefore, continuity of care during high-risk prenatal care, in the puerperium and for the newborn is impaired. In addition, it was observed that the knowledge about SUS by the workers interviewed is deficient and the content is little approached during undergraduate programs. Conclusions: There should be training for primary and tertiary care professionals in an integrated way, with regard to SUS principles and guidelines, especially in relation to referral and counter-referral. It is also necessary to train physicians and nurses of the UBS in prenatal care. For this study, which is a Professional Master\'s Degree, two tools, the flowchart and the follow-up form of high-risk pregnant women, were developed to be used in the exchange of information within PHC and tertiary care. The form must be completed by the Maternity monthly, and later, by direct mail, sent to the UBS.

<p>The experience of pregnancy and childbirth is a central life event with special implications for women at high risk. This thesis describes the meaning of pregnancy, childbirth and midwifery care in four qualitative interview studies based on the lifeworld theory. Women were interviewed during pregnancy and within one week after childbirth. Midwives were interviewed concerning midwifery care for women at high risk. In an intervention study, childbirth experience as reported through a post partum questionnaire was compared between women receiving standard care and women who had formulated a birth plan preceded by a questionnaire on their expectations and feelings about childbirth. </p><p>The findings emphasise that childbearing women at high risk live in an extremely vulnerable situation. The vulnerability is obvious in the use of an individual birth plan, where negative feelings become more frequent in women at high risk than in those with normal pregnancy and childbirth. During pregnancy the women feel a moral commitment towards the child, including feelings of objectification and of exaggerated responsibility. During an obstetrically complicated childbirth the essential meaning is the women’s desire to be recognised and affirmed as individual persons. Like women with normal pregnancy and childbirth, they need an emotionally present midwife who sees, give trust and supports. </p><p>Good midwifery care of childbearing women at high risk is synthesised as "genuine caring in caring for the genuine". The ethos of caring constitutes the basis of caring. Women’s transition during pregnancy and childbirth is described as a genuinely natural process. Midwives have a special responsibility to encourage and preserve this process within women at high risk. The caring relationship is the core and the most essential tool in the care. Distinctive features in the midwifery care are embodied knowledge, physical as well as emotional presence, sensitivity, a mutual dialogue including shared control between midwife and woman, and confirmation and support of the genuine in each woman. The midwifery care is a struggle and a balance between natural and medical perspectives.</p>

The University Hospital of Liège has 955 beds in 8 intensive care units, 15 medical wards, 10 surgical wards and 1 paediatric ward. Approximately 36,000 patients are admitted each year, giving a total of 265,000 patient-days hospitalization. Extended-spectrum beta-lactamase-producing Enterobacteriaceae (E-ESBL) constitute, along with methicillin-resistant Staphylococcus aureus (MRSA), the main multi-resistant bacteria recovered in our hospital. The aims of the present study were to: - evaluate the epidemiology of E-ESBL - evaluate the impact of an infection control programme to reduce the spread of E-ESBL in the University Hospital of Liège. In order to do this, several studies were carried out between 2001 and 2007: 1. Determination of the high risk units in the CHU (2001) The high risk units were determined by comparing the incidence rates of each type of unit. Two types of high risk unit were identified in this way: the Intensive Care Units (ICUs) and the Onco-Haematology Unit. 2. Epidemiology of E-ESBL in the Onco-Haematology unit (2002-2003 and 2005-2006) Digestive tract colonization by E-ESBL was found to be relatively high (7.3%) and this explains the high incidence of E-ESBL in Onco-Haematology in comparison with the rest of the hospital. However, the clinical gravity associated with exposure to the risk factor (digestive tract colonization by E-ESBL) was found to be relatively weak. 3. Importance of digestive tract colonization by E-ESBL in General ICUs (2002-2003) Digestive tract colonization by E-ESBL was found to be relatively common (8.8%) and faecal carriage of E-ESBL was found to be a good marker for infection with E-ESBL at another body site. Even though the number of infected patients was found to be low, the risk of infection due to E-ESBL was multiplied by 14.7 in a group of digestive carriers of E-ESBL with regard to a group of non carriers. Our data also showed that Enterobacter aerogenes is the most frequent species producing extended-spectrum beta-lactamase (ESBL) and that TEM-24 is the most prevalent ESBL produced by E-ESBL species in our ICUs. No CTX-M-type genes were identified. With regard to antibiotic susceptibility, meropenem and cefepime appeared to be the most active agents against the majority of isolates. 4. Impact of an infection control programme to reduce the spread of E-ESBL (2006-2007) A surveillance programme was carried out to evaluate the implementation of infection control procedures including surveillance of ESBL-producing strains, utilization of computer alerts for E-ESBL positive patients and the application of contact precautions for colonized or infected patients. Infection control compliance observations were performed by trained referring nurses. During the 2 years of application, one or more E-ESBL were identified in 500 patients. A total of 2268 internal messages regarding the identification of E-ESBL were sent within the hospital, among which 91.84 % were received (at least 1 for every patient). An alert was associated with 406 patients, who were always hospitalized as the identification of the E-ESBL by the laboratory was obtained. A total of 257 registration forms were filled in by the referring nurses, resulting in a survey compliance of 63%. This survey showed that door signs identifying positive patients, hydro-alcoholic solution and gloves were present in 90% of the cases, but that gowns were only present in 59%. The overall incidence of nosocomial acquisition of E-ESBL between 2006 and 2007 was 0.92/1000 patient-days, more or less the same as in 2002. In relation to this research, several questions remain: - Even though the rates of digestive tract colonization with E-ESBL in the 2 types of high risk unit were found to be more or less the same (7.3 and 8.8%), the impact on infections due to E-ESBL was very different. - Are the infections due either to E-ESBL endogenous infections (owing notably to the use of broad spectrum antibiotics) or to secondary infections (resulting from cross-transmission) or to both? The implementation of an infection control programme to limit the spread of E-ESBL has been based on the limitation of the cross-transmission of these micro-organisms. An enhanced barrier precautions policy has been in place in our institution for 2 years, and we have seen no erosion in compliance. We should not however lose sight of the fact that, whatever the institutional policy for the management of multi-resistant bacteria, the correct application of standard precautions for all patients is the first measure to limit the cross-transmission of all micro-organisms.

<p>The main sources of teacher stress stem from difficulty in maintaining classroom discipline, time pressures, workload demands, excessive change, being evaluated by others, challenging relationships with colleagues and poor working conditions. This study therefore highlights the significant relationship between occupational stressors and the stress experienced by teachers at high risk secondary schools in the Western Cape. Occupational stress is related to job satisfaction, job overload and job control. The coping strategies of teachers at high risk secondary schools are explored. The results indicate that there were no significant relationships between teacher stress and job satisfaction, job overload and job control at high risk secondary schools in the Western Cape. Job satisfaction however, showed an inverse, albeit not significant relationship to teacher stress. Furthermore, male and female teachers respond differently to these occupational stressors. Females were more prone to the experience of stress than males. The recommendations are based on the conclusions drawn from the study. In conclusion, occupational stress is considered a major source of stress for teachers, which needs to be addressed more vigorously at high risk secondary schools in the Western Cape.</p>

研究者採用質性訪談方法，以高風險家庭處遇方案為場域，邀請執行該方案之督導員及社工員各六位為研究對象，運用宋麗玉與施教裕(2010)所擬定之「社會工作處遇的服務項目和結果指標：概念架構及操作定義」為成效指標之參考，進行個別訪談與資料收集。本研究主要探討高風險家庭處遇服務的社工督導模式，以及在不同督導模式下，社工員在「兒少成長發展」、「成人主要照顧者的改善發展」、「整體家庭功能的增強提昇」、「案家週邊社會支持體系」四大工作成效層面之情形。研究結果發現六種督導模式，分別為：「優勢觀點取向督導模式」、「生態系統取向督導模式」、「焦點解決取向督導模式」、「詮釋學取向督導模式」、「工具性督導模式」，以及「表達性督導模式」。於工作成效上，經社工員處遇後，在「兒少的成長發展層面」上，不論是一般兒少或是特殊兒少，經相關社會資源輸入後，如飲食、衛生、醫療、教育等系統，已使兒少漸漸步入正常的發展階段，發揮兒少自身之潛能，轉變成身、心、靈皆較為圓滿之狀態；在「成人主要照顧者的改善發展層面」上，原先家中之主要照顧者，因自身疾病因素或自我功能不足之情形，經社工的協助與鼓勵，多可獲得進一步的醫療處置以及良好的社會支持系統，發揮既有之社會功能，減緩低落的心理狀態，並以兒少之最佳利益為優先考量，以照顧兒少為其目標，提升本有之照顧功能；在「整體家庭功能的增強提昇層面」上，顯而易見的即是主要照顧者與兒少之間，多可站在雙方之立場，彼此接納與尊重，共同為家庭目標努力，各自扮演好應盡之角色義務，維持家庭之順利運行，使整體家庭功能有所提昇；在「建構案家週邊社會支持體系層面」上，經社工員引入正式與非正式資源後，案家危機狀況多可獲得即時性的改善，使家庭狀態趨於穩定，更重要的是案家在此過程擁有能力，當家庭需求無法滿足時，案家主動找尋社會資源以自我協助，預防家庭危機之再次出現。此外，經不同督導模式下的社工員，其工作成效亦可見其特殊性，如優勢觀點取向督導模式，使社工員在工作成效指標的四大面向，呈現多元的面貌，尤其在「成人主要照顧者的改善發展層面」、「整體家庭功能的增強提昇層面」，以及「建構案家週邊社會支持體系層面」上有突出的表現；生態系統取向督導模式，則在「兒少的成長發展層面」、「整體家庭功能的增強提昇層面」，以及「建構案家週邊社會支持體系層面」上擁有明顯表現；焦點解決取向督導模式，其在「整體家庭功能的增強提昇層面」上多有助益；詮釋學取向督導模式，主要展現於「成人主要照顧者的改善發展層面」。最後，研究者建議在政策規劃上，政府可強化社會工作督導員職能培訓與效能提升，並將該成效指標納入政策內容與高風險家庭個案管理系統；在實務工作上，建議督導員善用社會工作理論於督導過程，並建構出屬於自身的督導模式來模塑社工員的工作表現，以及實際運用該成效指標於處遇工作中。 / The researcher, applying the qualitative interview research in the field of the high-risk family service project, interviewing with six supervisors and six social workers in the project by applying the “complete conceptual framework and operational definition of service classification and outcome indicators” proposed by Song & Shih (2010) to gather data. Our research explored the social work supervision models for the services of high-risk family treatment and social workers’ outcomes in the areas of “child development”, “care takers’ improvement”, “family function empowerment” and “informal social support network”.According to our findings, six supervision models, “strengths perspective-approached supervision model”, “ecological systems-approached supervision model”, “solution-focused approached supervision model” , “hermeneutics-approached supervision model”, “instrumental supervision model” and “expressive supervision model”, all displayed work effectiveness as the treatments by social workers. In the area of “child development”,they inputted social resources such as diet, health, medical and education systems, to enable both normal and special children to begin to move into normal development stage for exhibiting their own potential and transforming into more successful physical, mental and spiritual state. In the “area of care takers’ improvement”, most of the main care takers of families, who had previously suffered from their own diseases or insufficient self-functions, were given better medical treatments and good social support system through the assistance and encouragement from the social workers, with their depressed mental state alleviated, and their inherent function of care taking giving priority to the consideration of best interests of children and setting the goal at care of children.In the “area of family function empowerment”, obviously both the main care takers and the children became more able to be take the stand points of each other to accept and respect each other to work hard jointly for the family’s aim, which each playing its own part well to sustain the smooth operation of the family and enhance the family function as a whole. In the “area of constructing of informal social support network”, most of the families of the case had their crises improved promptly after the social workers introduced formal and informal sources. Stabilizing the family status, and, more importantly, once these families possessed such capability during the treatment process, they would take initiatives in seeking social resources to self-help when their needs cannot be met, for preventing the family crises from re-occurring.In addition, social workers under different supervision models also showed their uniqueness in work effectiveness. For example, the strengths perspective-approached supervision model enabled social workers to exhibit diversely in the four areas of work effectiveness indicators, particularly the “area of care takers’ improvement”, the “area of family function empowerment” and the “area of constructing informal social support network”, where outstanding performances were seen. With the ecological systems-approached supervision model, notable performances were seen in the “area of child development”, the “area of family function empowerment” and the “area of constructing informal social support network”. The solution-focused approached supervision model helped greatly in the “area of family function empowerment”. The hermeneutics-approached supervision model stood out in the “area of care takers’ improvement”. At last, the researchers recommend that the governments, in formulating their policies, can strengthen the capacity training and efficacy increase for social work supervisors and take the outcome indicators as part of the policy contents and case management systems of high-risk families. Regarding the practice, we recommend that supervisors make good use of the theories of social work in their supervisory processes and construct supervision models that are for themselves to shape the performance of social workers and to apply the outcome indicators in the work of treatment.

The term criminal career is used to describe the course or progress of criminal activity: its onset, duration, termination, severity, and change in severity. Such a term has important implications, given that significant criminal justice, social, and health policies such as crime control, parole, and correctional treatment and management are predicated on achieving the reduction of criminal careers of serious, repeat offenders. Despite its conceptual simplicity, however, criminal career is often treated as having no depth or scope, for example, merely as the number of crimes or length of prison sentence. These indices often give no or little consideration to criminal career parameters and tend to account for only a small portion of the construct of criminal careers. Ideally, a simple metric to measure the onset, duration, termination, severity, and change in severity of a pattern of criminal activities is needed to facilitate the description and measurement of criminal careers of offenders. <p>The Criminal Career Profile (CCP), which uses commonly available criminological information and requires minimal professional skills to execute, can be considered a simple and precise measure of criminal careers. The CCP is a chronological representation on a Cartesian plane of the time in years an offender has spent in prison (y-axis) plotted against the time in years spent out of prison (x-axis) of all incarcerations and time spent in the community. Given that the CCP is a step function, a regression line can be generated. Serious crimes are generally given longer sentences, and more time in than out of prison would generate a steeper regression line. Shallower regression lines result from less time in than out of prison. As such, the CCP regression line can be considered an indication of the seriousness of offending, and the slope or angle of the regression line can be considered a quantitative index of criminal career severity. Larger slopes or angles (used in this Program of Research) suggest more serious criminal careers. Conversely, smaller slopes or angles suggest less serous criminal careers. Taken altogether, the CCP can provide a quantitative measure of criminal careers: its onset (age at first conviction, which is plotted as the first point on a CCP graph), duration (total time in and out of prison since onset), severity (CCP slope/angle), change in severity (change in CCP slope/angle), and termination (end point or when the CCP slope or angle becomes smaller and closer to 0).<p>This Program of Research was done to assess the CCPs validity and utility in measuring offenders criminal career. More specifically, the investigation focused on the seriousness of criminal careers. A number of criteria were used to validate the CCP angles ability to measure criminal career severity. In Study 1, psychopaths and violent recidivists showed a significantly larger CCP angle than nonpsychopaths and violent nonrecidivists, respectively. Finer groupings based on risk (high, medium, and low), a number of risk measures (Psychopathy Checklist Revised, Violence Risk Scale, and Violence Risk Scale Sexual Offender Version), and different types of offenders (i.e. violent, nonviolent, sexual, Dangerous Offenders) were used in Study 2. Two consistent findings across different groups of offenders in Study 2 were CCP angles significantly varied as a function of risk group and correlated with risk ratings. The pattern of results was that larger CCP angles tended to be associated with worse risk groups. In Study 3, both treated offenders and treatment dropouts showed a reduction in CCP angles from pre- to post-treatment. A nonsignificant interaction of group by treatment, however, suggests that post-treatment changes could not be attributed to treatment. Finally, Study 4 showed that CCP angles change with age. Taken altogether, the results of the four studies provided converging evidence for the validity of the CCP as a measure of criminal careers and the CCP angle as a measure of criminal career severity.