Introdução: O sofrimento psíquico infanto-juvenil foi historicamente atrelado às limitações cognitivas (idiotia infantil) e à necessidade de ação sobre o abandono e delinquência juvenil e traz em seu bojo práticas de cuidado historicamente segregadoras e médico-científicas moralizantes. A assunção do Estado às práticas de cuidado à infância e adolescência principalmente nos movimentos reformadores da década de 80 no Brasil construção do Sistema Único de Saúde e Reforma Psiquiátrica reivindicou um novo olhar em torno desse cuidado, o que foi concretizado na construção de uma política de cuidado infantojuvenil enredada estrategicamente nos CAPS infantojuvenis, bem como na necessidade dos processos de trabalho que apoiassem práticas interseçoras e relacionais produtoras de usuários sujeitos de direitos nesses estabelecimentos. Objetivo: Evidenciar a relação entre as modalidades de produção de cuidado em saúde mental e os processos de trabalho desenvolvidos em um CAPS ADi. Método: cartografia dos processos de trabalho com profissionais de um CAPS ADi de São Bernardo do Campo - São Paulo e dois usuários do estabelecimento. Utilizou-se a metodologia do caso-traçador na congregação de quatro focos de análise sobre dois casos emblemáticos atendidos no CAPS: observação do cotidiano de trabalho, caracterização, grupos focais com profissionais e entrevistas com dois usuários. Resultados: Os resultados apontaram para uma dinâmica de trabalho bastante complexa e atravessada por questões cotidianas do serviço, bem como por diferentes concepções acerca do cuidado, do que é projeto terapêutico e de como cuidar de adolescentes que trazem histórias sociais tão diversas quanto às suas famílias e situações de vulnerabilidade nas quais o uso abusivo de drogas se faz, por vezes, secundário em relação à demanda vivenciada dia-a-dia. Conclusão: É de suma importância construir espaços de reflexão e autoanálise para que os profissionais possam partilhar e rediscutir os processos de subjetivação gerados a partir de suas ações nos usuários e em si próprios, bem como, resignificar o sentido do cuidado e da existência de um Centro de Atenção Psicossocial voltado para crianças e adolescentes que fazem uso abusivo de álcool e drogas / Introduction: The child and youth psychological suffering was historically tied to cognitive deficits and the need for action on child abandonment and juvenile delinquency. They will be cared for the practices historically segregated and medical-scientific moralizing. Nevertheless, the State care practices for childhood and adolescence, the emergence of specific knowledge about child and youth development, and especially the reform movements of the 80s in Brazil the construction of integrated and universal health system, and psychiatric reform - demanded a new point of view around that care, what was achieved later in the construction of a policy of child and youth careful established in Child and Youth Psychosocial Care Centers CAPSi and in need of work processes that supported relational practices intercessors and producing users having rights in these establishments. Objective: It aims to show the relationship between modes of production of mental health care and work processes developed in Child and Youth Psychosocial Care Center to treat drug abuse CAPS ADi. Methods: The work process mapping with professionals and two users of Chlid and Youth CAPS to treat drug abuse at São Bernardo do Campo - São Paulo. We used the methodology of \"case-tracer\" in the congregation of four foci analysis on two emblematic cases seen at CAPS: observation of daily work, characterization and focus groups with professionals and interviews with two users. Results: The results showed a dynamic work quite complex crossed by the everyday issues of service, as well as different conceptions of care, which is the therapeutic project and how to care for adolescents who bring social stories as diverse as their families and vulnerability situations in which drug abuse is done sometimes secondary demand experienced dayto-day. Conclusion: It is extremely important to ensure spaces for reflection so that professionals can share and revisit the processes of subjectivity generated from their actions on users and themselves as well, reframe the meaning of care and the existence of a Psychosocial Center facing children and adolescents who abuse alcohol and drugs

現階段的兒童少年保護工作中，社會工作專業的介入都與法令的執行及公權力角色息息相關，強制性的工作乃是依據兒童及少年保護的相關立法規定而進行強制性的介入。在兒童及少年保護工作中，以緊急安置對兒童及少年的家庭、親子關係及相關權益有最直接的影響，而事實上，在強制性的介入中，家庭弁鄋熊�估及處遇工作是一項整合修復兒童及少年個人與家庭的重要過程，並確保兒童少年及其家庭二方的權益皆能受到保障。本研究係針對屏東縣91年至94年間處理的78件兒童少年緊急安置案件，採量化的文件分析法及質性的深度訪談蒐集研究資料，希望透過本研究檢視過去緊急安置的處遇方式，並提出未來在兒童及少年保護過程中緊急安置發展方向的建議。研究者以家庭處遇的觀點來探討兒童及少年在經過緊急安置及提供受虐者與施虐者必要的輔導後，家庭維繫或家庭重整對兒童及少年權益的影響。研究者透過個案處遇記錄及與執行兒少保護實務的工作人員訪談，針對屏東縣在執行兒童及少年保護工作的緊急安置處遇提出下列研究成果與建議：1.目前兒童及少年保護的工作模式，大致仍以提供兒童及少年最佳安全環境為主要目的，緊急安置對案主權益的維護，與後續的家庭評估與處遇有重要的相關，是以加強專業網絡的建構及提昇專業人員知能才能有效執行法令對兒童及少年的保護；2.治本的辦法則為加強社會教育強化父母對子女的責任觀念；3.若評估家庭弁鄐w無法重建，?維護兒童及少年的權益，替代性的服務是必要的處遇觀念，讓兒童及少年有機會重新出發建立新的生活能力。 / Presently, the involvement of professional social work is related closely with the execution of laws and the gov ern ment when we talk about the protection of children and teenagers. Forceful modes are based on the laws of children and teenagers protection. However, what influences the relati on and rights of children and teenagers is crisis interven tion and placement. In fact, the evaluation of family fu nction and family treat ment is an important processof int egrating th econnection of individual and family in forceful mode. It can also guarantee the rights of both child ren and family. This research is based on 78 cases of teenagers’ crisis i ntervention and pl acement in Pintung County fro m 2002 to 2005. It is a quantified document analysis and a qualified deep interview as well . The purpose of this article is to discuss the way o f the urgent ensconced treatment in the past, and give advices to improve the quality of children and teenage protection in the future. This article uses the view of family treat ment approach to discuss the in fluence of victims, offenders, and fa mily in children and teenagers urgent ensconced treatment. Based on the individual reco rds and interview with workers who work with children and teenagers, there are some conclusions and suggestions to urgent ensconced treat ment of children and teenagers protection in Pintung county as following: 1. At present , the main goal o f the children and teenagers protection is still providing the safest circu mstances. The way o f crisis int ervention and placement has strong connection with guarantee of client s’ rights and family evaluation in the future. To improve the function of child ren andteenagers protection more efficiently, we should strengthen the professional netwo rk and elevate the knowledge of professional workers. 2. The best way to solve the problem is to enhance parent s’ responsibility to their children. 3. If fami ly function could not be rebuilt, alternative service would b e a necessary to ensure children and teenagers’ rights. It can give them a chance to develop their social ability as well. / 目錄 中文摘要……………………………………………………………………i 英文摘要…………………………………………………………………ii 誌謝………………………………………………………………………iii 目錄………………………………………………………………………iv 表目錄 ………………………………………………………………… viii 圖目錄……………………………………………………………………x 第 一 章 緒 論 …………………………………………………………1 第一節 研究背景………………………………………………… 2 第二節 研究動機 ……………………………………………3 第三節 研究目的 ……………………………………………4 第四節 名詞界定 ……………………………………………5 第 二 章 文獻探討 ………………………………………………… 8 第一節 兒童及少年保護緊急安置的概念 ……………………8 第二節 兒童及少年保護、福利相關法規 ……………………9 第三節 受虐類型……………………………………………… 9 第四節 兒童及少年保護服務處遇模式 ……………………11 第五節 家庭維繫與家庭重整 ………………………………11 第六節 過去相關研究 ………………………………………13 第 三 章 研究方法 …………………………………………………… 15 第一節 研究架構…………………………………………… 15 第二節 研究假設…………………………………………… 16 第三節 研究變項定義……………………………………… 17 第四節 研究流程…………………………………………… 21 第五節 資料蒐集…………………………………………… 21 第六節 信度與效度………………………………………… 22 第七節 資料分析方法……………………………………… 23 第 四 章 兒少保護緊急安置的個案紀錄分析 …………………… 25 第一節 受虐者與施虐者…………………………………… 25 第二節 受虐類型…………………………………………… 31 第三節 緊急安置…………………………………………… 32 第四節 受虐者與施虐者處遇……………………………… 32 第五節 家庭處遇… …………………………………………33 第六節 受虐者基本特質與受虐原因交叉分析…………… 34 第七節 討論…………………………………………………… 49 第 五 章 緊急安置處遇社工員的質性訪談分析………………… 51 第一節 緊急安置的處遇及意義 ……………………………… 51 第二節 安置資源及公、私部門合作機制………………… 54 第三節 年幼及特殊需求的兒少安置……………………… 56 第四節 處遇計畫的評估與擬定…………………………… 58 第五節 緊急安置的期限…………………………………… 59 第六節 緊急安置的法令完善性…………………………… 60 第七節 緊急安置處遇司法處遇的探討…………………… 61 第八節 研究結果討論……………………………………… 63 第 六 章 結論與研究建議…………………………………………… 69 第一節 結論…………………………………………………… 69 第二節 研究的建議…………………………………………… 70 第三節 研究的限制…………………………………………… 71 參考書目………………………………………………………………… 72 附錄一 臺閩地區兒童及少年保護執行概況表………………… 75 附錄二 兒童及少年福利法……………………………………… 76 附錄三 兒童及少年福利法施行細則…………………………… 89 附錄四 屏東縣兒童及少年虐待暨被疏忽研判指標…………… 92 附錄五 屏東縣強制性親職教育處遇評估表…………………… 100 附錄六 家庭暴力與兒童少年保護事件通報表…………………… 103 附錄七 訪談同意書……………………………………………… 105 附錄八 訪談大綱…………………………………………………… 106 附錄九 訪談人員基本資料……………………………………… 107 圖表目錄 圖 1 兒少保護緊急安置處遇研究架構…………………………… 16 表 1 1990-2005年有關兒少保護處遇博碩士論文篇數…………… 14 表 1.1 1990-2005年相關重要兒少保護處遇的研究者及研究項目…… 14 表 2 受虐原因分析…………………………………………………… 28 表 2.1 受虐主基本資料分析…………………………………………… 29 表 2.2 施虐者身份與施虐原因分析…………………………………… 30 表 3 受虐類型分析………………………………………………… 31 表 4 緊急安置方式分析…………………………………………… 32 表 5 受虐者與施虐者處遇分析………………………………… 33 表 6 家庭處遇分析……………………………………………… 34 表 7 受虐者基本資料與受虐原因交叉分析表………………… 36 表 7.1 受虐者基本資料與受虐原因交叉分析表(續)………………… 36 表 8 通報來源及受虐原因交叉分析…………………………… 37 表 8.1 通報來源及受虐原因交叉分析(續)…………………………… 38 表 9 家庭類型與受虐原因交叉分析…………………………… 39 表 9.1 家庭類型與受虐原因交叉分析(續)………………………… 39 表 10 受虐者基本資料與受虐原因交叉分析………………………… 40 表 10.1 受虐者基本資料與受虐原因交叉分析(續)……………… 41 表 11 施虐者教育程度與受虐原因交叉分析………………………… 42 表 12 施虐者年齡與受虐原因交叉分析……………………………… 43 表 12.1 施虐者年齡與受虐原因交叉分析(續)…………………… 43 表 13 施虐者身份與受虐原因交叉分析…………………………… 44 表 13.1 施虐者身份與受虐原因交叉分析(續)……………………… 45 表 14 施虐者教育程度與受虐類型交叉分析表…………………… 46 表 15 施虐者年齡與受虐類型交叉分析表……………………… 47 表 15.1 施虐者年齡與受虐類型交叉分析表(續)…………………… 47 表 16 施虐者身份與受虐類型交叉分析………………………… 48 表 16.1 施虐者身份與受虐類型交叉分析(續)……………………… 48

學界常以嚇阻理論觀點詮釋解放軍的外在戰略作為，但經由本研究透過嚇阻理論分析檢證的結果，發現事實上中共有其一貫的「威懾戰略」思維模式，並且為解放軍核心戰略「積極防禦」的依據，此戰略思維內涵承襲中國傳統戰略文化與原則，其實際意義和中共學界定義的威懾戰略不同。「威懾戰略」思維也是解放軍在建構與運用戰略武力時的根本依循原則，而非根據嚇阻理論產生的嚇阻戰略，因此以嚇阻戰略的標準來檢驗與分析解放軍戰略作為，將不能得到正確解答。 解放軍從早期建構核戰略武力開始，即是出自於現實戰略利益考量，並不只是如中共官方所稱，要打破大國核壟斷與追求徹底消滅核武器等理想性、道德化說詞；解放軍隱晦的「不首先使用」核武原則，更是「威懾戰略」思考下，避免引起強國攻擊，以換取戰略武力發展空間的一項策略。隨著國際戰略局勢以及中共安全認知轉變，在美國發展彈道飛彈防禦體系以及調整核武戰略的情況下，解放軍將會持續建構包含非核戰略武力在內的戰略打擊力量，但在核戰略武力建構方面將會有所節制，置重點於技術提升和多元發展，以確保解放軍能在不改變既有原則的基礎上，更加彈性靈活運用各式戰略武力，一方面維持威嚇的效果，另一方面也能在必要時配合「威懾戰略」動用武力，達成中共所賦予解放軍的任務。 關鍵詞：中共軍事、嚇阻理論、嚇阻戰略、威懾戰略、戰略武力、不首先使用 / Researchers often apply the concept of Deterrence Theory to explain the outward strategic actions of People’s Liberation Army (PLA). However, through comprehensive analyses and examinations of Deterrence Theory, the research result indicated that PLA has created its own strategic logic of “Threat and Deterrent Strategy” which became the foundation of PLA’s core military strategy--Active Defense. In addition, this kind of strategic thinking which can be considered as the heritage of traditional Chinese military culture and principle is significantly different from the concept and measures of Deterrence Theory commonly agreed by scholars. “Threat and Deterrent Strategy” also became the foundation of PLA’s main military strategy “Active Defense”. “Threat and Deterrence Strategy” is PLA’s principle of building and operating its strategic weapon. Applying the concept of Deterrence Theory to explain PLA’s military actions may be inappropriate and result in misunderstanding because the concept and application of “Threat and Deterrence Strategy” are different from Deterrence Theory. Even though China official claimed that the goal of obtaining nuclear power is based on an ideal and proper purpose such as to break the exclusive development of nuclear weapon by certain countries and abolish nuclear weapon eventually, the reason why PLA developed nuclear weapon is because of the military advantages and strategic interests from obtaining nuclear power. PLA announced its “no-first-use” principle of using nuclear weapon without notifying the proviso is a typical example of playing “Threat and Deterrence Strategy” so that China can develop its strategic weapon without creating opposition from other countries. Along the strategic interactions among countries, the changing attitude toward national security in China, the development of Ballistic Missile Defense System in U.S, and the adjustment of using nuclear weapon and its strategy, PLA will keep improving its strategic weapon, including nuclear and non-nuclear. However, PLA will not speed up its development of nuclear weapon. Instead, PLA will emphasize more on improving the capacity and variety of its strategic weapon so that PLA can utilize all kinds of strategic weapon flexibly and ingeniously. On the one hand, improving military strength can ensure the effectiveness of deterrence; on the other hand, cooperating “Threat and Deterrence Strategy” and military actions can help PLA to complete the mission from China. Keywords: China Military, Deterrence Theory, Deterrence Strategic, Threat and Deterrence Strategy, Strategic Weapon, No first use

Depuis l’arrêt « Mercier » en 1936, la jurisprudence française a consacré la présence d’un contrat médical entre médecin et patient. L’obligation de soins est l’obligation principale du médecin dans ce contrat, elle en est l’objet déterminant. Cependant, avec les progrès réalisés et l’accroissement des exigences de la société, la jurisprudence a renforcé les obligations imposées au médecin en créant ainsi, à sa charge, certaines obligations accessoires, l’obligation de sécurité et l’obligation d’information. Ces obligations ainsi consacrées légalement en France en 2002, sont pour les deux assez importantes afin de maintenir l’équilibre dans la relation de soins. Cette évolution considérable en France n’a pas eu la même importance au Liban. Il existe ainsi beaucoup de carences législatives et jurisprudentielles en matière des obligations médicales. Et bien que le Code de déontologie médicale libanais évoque l’obligation de soins et l’obligation d’information, pour dire que les dispositions du texte sont imprécises. Par ailleurs, il n’existe aucune loi régissant l’obligation de sécurité médicale. Malgré la promulgation de la loi n° 574 du 11 février 2004 relative aux droits des patients et au consentement éclairé, ses dispositions restent assez limitées et son application demeure délicate. Une intervention législative est donc, souhaitable au Liban s’inspirant du législateur français afin de créer des dispositions légales régissant ces obligations d’une manière plus claire, organisée et adaptée aux besoins de la société. / Since 1936 French courts acknowledged the presence of a contract between patient and physician. The obligation to treat was the determinant aspect in this binding document. The main goal was to ensure a balanced relationship between the physician and his patient and an efficient treatment services, therefore, other obligations had to be enforced by the Supreme Court to guarantee an efficient system in an evolving society. In 2002, security and information became an added legal bond between patient and doctor in France. Despite being mush needed, these innovations did not create the same positive echo inside the Lebanese legal system. On this matter, a law detailing the obligation of security is absent, physicians must only answer to ethical codes regarding the medical treatment of their patients. Progress was made in February 2004 with the n° 574 patient’s rights and consent law. Nonetheless, mirroring the French legal system with a new reform on this subject comes with a great value, and will give the Lebanese professional and his patient a new solid ground capable of coping with the evolution of our society.

Made available in DSpace on 2014-12-17T15:01:20Z (GMT). No. of bitstreams: 1 WilaciEFJ.pdf: 1838358 bytes, checksum: 40ec11f34b65cc0544a9b15c91dae65a (MD5) Previous issue date: 2002-04-05 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior / The present work had as objective to apply an experimental planning aiming at to improve the efficiency of separation of a new type of mixer-settler applied to treat waste water contaminated with oil. An unity in scale of laboratory, was installed in the Post-graduation Program of Chemical Engineering of UFRN. It was constructed in partnership with Petrobras S.A. This called device Misturador-Decantador a Invers?o de Fases (MDIF) , possess features of conventional mixer-settler and spray column type. The equipment is composed of three main parts: mixing chamber; chamber of decantation and chamber of separation. The efficiency of separation is evaluated analyzing the oil concentrations in water in the feed and the output of the device. For the analysis one used the gravimetric method of oil and greases analysis (TOG). The system in study is a water of formation emulsified with oil. The used extractant is a mixture of Turpentine spirit hydro-carbons, supplied for Petrobras. It was applied, for otimization of the efficiency of separation of the equipment, an experimental planning of the composite central type, having as factorial portion fractionary factorial planning 2 5-2, with the magnifying of the type star and five replications in the central point. In this work, the following independents variables were studied: contents of oil in the feed of the device; volumetric ratio (O/A); total flowrate ; agitation in the mixing chamber and height of the organic bed. Minimum and maximum limits for the studied variables had been fixed according previous works. The analysis of variance for the equation of the empirical model, revealed statistically significant and useful results for predictions ends. The variance analysis also presented the distribution of the error as a normal distribution and was observed that as the dispersions do not depend on the levels of the factors, the independence assumption can be verified. The variation around the average is explained by 98.98%, or either, equal to the maximum value, being the smoothing of the model in relation to the experimental points of 0,98981. The results present a strong interaction between the variable oil contents in the feed and agitation in the mixing chamber, having great and positive influence in the separation efficiency. Another variable that presented a great positive influence was the height of the organic bed. The best results of separation efficiency had been obtained for high flowrates when associates the high oil concentrations and high agitation. The results of the present work had shown excellent agreement with the results carried out through previous works with the mixer-settler of phase inversion / O presente trabalho teve como objetivo otimizar a efici?ncia de separa??o de um novo aparelho do tipo misturador-decantador aplicado ao tratamento de ?guas residu?rias contaminadas com petr?leo. Foi utilizado um equipamento em escala de laborat?rio, instalado no Programa de P?s-gradua??o em Engenharia Qu?mica da UFRN, que foi constru?do em parceria com a Petrobras S.A. Este aparelho denominado Misturador-Decantador ? Invers?o de Fases (MDIF), possui caracter?sticas de um misturador-decantador convencional e de uma coluna tipo spray. O equipamento ? composto de tr?s partes principais: c?mara de mistura; c?mara de decanta??o e c?mara de separa??o. A efici?ncia de separa??o ? avaliada analisando-se as concentra??es de ?leo em ?gua na alimenta??o e na sa?da do aparelho. Para a an?lise utilizou-se o m?todo da an?lise de ?leo e graxas (TOG) por gravimetria. O sistema em estudo ? uma ?gua de forma??o emulsionada com ?leo. O extratante utilizado ? uma mistura de hidrocarbonetos denominada de Aguarr?s, fornecido pela Petrobras. Aplicou-se, para a otimiza??o da efici?ncia de separa??o do equipamento, um planejamento experimental do tipo central composto, tendo como por??o fatorial o planejamento fatorial fracion?rio 2 5-2, com a amplia??o do tipo estrela e cinco repeti??es no ponto central. Neste trabalho, estudam-se as seguintes vari?veis independentes: teor de ?leo na ?gua residu?ria de carga da coluna; rela??o volum?trica org?nico/aquoso (O/A); vaz?o efetiva total; agita??o na c?mara de mistura e altura do leito org?nico. Foram fixados limites m?nimos e m?ximos para as vari?veis estudadas de acordo com trabalhos realizados anteriormente. A an?lise de vari?ncia para a equa??o do modelo emp?rico, mostrou-se estatisticamente significante e ?til para fins preditivos. A an?lise de vari?ncia tamb?m apresentou a distribui??o do erro como uma distribui??o normal e observou-se que como as dispers?es n?o dependem dos n?veis dos fatores, a suposi??o de independ?ncia pode ser verificada. A varia??o em torno da m?dia ? explicada por 98,98%, ou seja, igual ao valor m?ximo explic?vel, sendo o ajuste do modelo em rela??o aos pontos experimentais de 0.98981. Os resultados apresentam uma intera??o muito forte entre as vari?veis teor de ?leo e agita??o na c?mara de mistura, tendo grande e positiva influ?ncia na efici?ncia de separa??o. Outra vari?vel que apresentou-se com grande e positiva influ?ncia foi a altura do leito org?nico. Os melhores resultados de efici?ncia de separa??o foram obtidos para altas vaz?es quando associadas a altas concentra??es de ?leo e alta agita??o. Os resultados obtidos no presente trabalho mostraram excelente concord?ncia com os resultados de trabalhos anteriores realizados com o misturador-decantador ? invers?o de fases

Hintergrund: Der Einfluss von rheumatoider Arthritis auf Psyche, Lebensqualität und Alltag der Patienten ist groß. Für eine positive Langzeitprognose sind frühzeitige Diagnosestellung und Therapieeinleitung entscheidend. Diese werden maßgeblich von den strukturellen Gegebenheiten der ambulanten rheumatologischen Versorgung beeinflusst. Hier zeigen sich trotz großer Fortschritte in den letzten Jahren weiterhin Defizite. Anhand einer Patientenbefragung in Leipzig sowie ländlichen Gebieten Sachsens sollen regionale Unterschiede und eventuelle Mängel in der ambulanten Versorgung sowie deren Einfluss auf die Lebensqualität, psychische Gesundheit und Entscheidungsfindungsprozesse untersucht werden. Methoden: Aus sechs Praxen in der Stadt Leipzig und drei Praxen in Kleinstädten (Naunhof, Plauen und Hoyerswerda) wurden Patienten mit der Erstdiagnose rheumatoide Arthritis im ersten Quartal 2011 mittels Fragebögen zu psychischer Gesundheit (Hospital Anxiety and Depression Scale und Short-Form-36-Health-Survey) sowie Entscheidungsfindungsprozessen (Decision Making Preference Scale) befragt. Ein eigens entwickelter Fragebogen erhob Beschwerde- und Behandlungsdauer sowie allgemeine medizinische Daten und Medikation. Ergebnisse: 19 Land- und 38 Stadtpatienten wurden eingeschlossen. Landpatienten suchten signifikant später den Hausarzt auf (Land 15, Stadt 12 Monate, p= .023). Die hausärztliche Behandlungsdauer bis zur Überweisung zum Rheumatologen betrug auf dem Land 5,4 und in der Stadt 2,4 Monate. Bei 70% der Stadt- und 40% der Landpatienten erfolgte die Überweisung innerhalb der ersten sechs Wochen. Die Gesamtdauer von Beschwerdebeginn bis zur Überweisung zum Rheumatologen war mit 20 Monaten auf dem Land signifikant länger als in der Stadt (15 Monate, p= .043). Die Wahl der Medikation durch den Rheumatologen hing signifikant mit der Herkunft der Patienten zusammen (p= .006). Nach Erstkontakt erhielten 65% der Land- und 55% der Stadtpatienten ein DMARD. In beiden Regionen wurde überwiegend mit Glukokortikoiden behandelt (Stadt 82%, Land 71%). Auf dem Land zeigten die Patienten weniger Interesse an Mitwirkung im partizipativen Entscheidungsfindungsprozess und waren mehrheitlich bereit, sich der Meinung des Arztes auch gegen den eigenen Willen anzuschließen. In der Stadt war der Wunsch nach aktiver Teilhabe an medizinischen Entscheidungen bei jüngeren und höher gebildeten Patienten signifikant größer als bei älteren oder bildungsfernen Erkrankten. Mit 21% wiesen tendenziell mehr Landpatienten depressive Symptome auf als in der Stadt (14%). Auf dem Land bestand häufiger der Verdacht auf krankheitsassoziierte Angststörungen. Zusätzlich litten die Patienten hier signifikant stärker unter ihren Schmerzen als in der Stadt (p= .026), wobei sich kein grundsätzlicher Unterschied in der gesundheitsbezogenen Lebensqualität ergab. Schlussfolgerung: In Stadt und Land zeigen sich Defizite in der ambulanten rheumatologischen Versorgung, wobei der Grad der Unterversorgung mit der Herkunft assoziiert ist und Landpatienten signifikant länger bis zum ersten Rheumatologenkontakt brauchen. Maßgeblich verantwortlich hierfür ist die verspätete Vorstellung der Patienten beim Hausarzt ebenso wie die ungleiche Facharztverteilung in Stadt und Land. Patienten auf dem Land sind tendenziell depressiver, passiver und schmerzgeplagter, wobei sich keine grundsätzlichen Unterschiede in der gesundheitsbezogenen Lebensqualität ergeben. Die Ergebnisse spiegeln Ärztemangel und infrastrukturelle Probleme wider. Weiterer Schulungs- und Aufklärungsbedarf zur verstärkten Bildung eines öffentlichen Bewusstseins für die Erkrankung rheumatoide Arthritis wird ebenso deutlich wie die Notwendigkeit für die Bahnung schnellerer Zugangswege zu rheumatologischer Behandlung.

[pt] Em função do crescente número de área contaminadas, identificadas nos grandes centros urbanos, é de crucial importância a evolução e o desenvolvimento dos processos relacionados ao tratamento destes locais, visando reduzir os riscos à saúde humana e ao meio ambiente, associados à presença dos contaminantes no meio subterrâneo. A presente dissertação tem como objetivo principal avaliar a eficiência de diferentes técnicas processuais, que poderiam ser aplicadas no tratamento de águas subterrâneas contaminadas, incluindo a ozonização e o uso de lodo ativado. Para isso, foram realizados ensaios de tratabilidade no laboratório do Institute of Sanitary and Environmental Engineering, da Universidade Técnica de Braunschweig, na Alemanha, os quais foram divididos em 3 etapas. A primeira etapa consistiu de um tratamento de caráter biológico, utilizando apenas o lodo ativado, coletado em estações de tratamento de efluentes sanitários, para a degradação de compostos orgânicos presentes em efluentes, artificiais e industriais, que simularam um efluente oriundo de um sistema de tratamento de uma área contaminada. A segunda etapa utilizou como técnica de tratamento, para o mesmo efluente, a ozonização, promovendo assim a oxidação química dos contaminantes. Por fim, foi utilizada uma combinação dos dois processos, sendo realizada a ozonização do efluente antes da degradação biológica. O objetivo desta etapa foi avaliar o incremento da biodegradabilidade do efluente por meio da ozonização. Os resultados obtidos indicaram, além da remoção da cor do efluente, uma efetiva redução dos valores de DQO, quando combinadas as duas técnicas de tratamento, sugerindo que a combinação das mesmas pode ser uma boa alternativa para o tratamento de efluentes de alta complexidade. / [en] Given the growing number of contaminated sites identified in large urban areas, it is of crucial importance the evolution and development of treatment processes for these sites, targeting the reduction of environmental and human health risks related to soil and groundwater contamination. The main goal of this dissertation is to evaluate the efficiency of various processing methods that could be applied in the treatment of contaminated groundwater, including the ozonation and activated sludge utilization. For that, jar tests were conducted in the laboratory of Institute of Sanitary and Environmental Engineering, at Braunschweig Technical University, in Germany, in three steps. The first step performed a biological treatment utilizing the activated sludge only which was collected from sewage treatment plants for the biodegradation of organic compounds present in effluents, both artificial and industrial, which simulated the effluent from a contaminated site treatment system. The second step utilized as treatment method, for the same effluent, an ozonation process, promoting the chemical oxidation of the contaminants. At last, a combination of both methods was tested where the ozonation was done prior to the biodegradation. The objective of this step was to evaluate the additional results of the biodegradation of the effluent when an ozonation process is done first. The results showed, in addiction of the color removal from the effluent, a larger reduction of DQO when both techniques are combined, suggesting that the combination can be a good alternative for treatment of high complexity wastewater.

The presence of non-metallic inclusions (NMIs) have critical effects on both the mechanical properties and machinability of steels. In the present thesis, one focus is to study the characteristics of deformed sulfides (MnS) for a stainless steel (3R65) and a tool steel (42CrMo4). Three groups of MnS inclusions were detected in the samples taken after deformation of the steel: i) type RS (sulfides with a Rod-like geometry), ii) type PS (sulphides with a plate-like geometry) and iii) type OS (oxy-sulfides). Here, the elongated inclusions present in both stainless and tool steels were studied more in detail using SEM to determine the tendency for the inclusions to break.  The results showed that three types of elongated MnS inclusions could be identified, namely UU, UB and BB. Here, ‘U’ represents the unbroken edge(s) of inclusion and ‘B’ represents the broken edge(s) of an inclusion. The presence of these three types of inclusions in samples collected both before and after a heat treatment was studied and the results showed that the heat treatment had a very small effect on the morphologies of the elongated MnS inclusions for both stainless steels (containing <0.1 mass % C) and tool steels (containing 0.42 mass % C).  In the second part of the thesis, the characteristics of chips after machining of a 157REM Ce-treated steel and a 157C reference steel was studied. Furthermore, the effect of the NMIs on the chip breakability during machining was determined. The results show that a Ce modification of a 157C steel transforms the NMIs from large size elongated inclusions to small size inclusion with a spherical shape. This leads to an improved machinability of 157C steels. In addition, a newly developed weight distribution of chips (WDC) method, based on the chip weight measurements, was used to determine the tendencies for breaking of chips. The results of this investigation showed that the chips that were obtained from the machining of 157C and the 157REM steels could be classified into the following three types: i) type I chips (with a geometry containing one arc) and having a weight of less than 0.08 g, ii) type II chips (with a geometry containing two arcs) and having weights between 0.08 g and 0.15 g, and iii) type III chips (with a geometry containing three or more arcs) and having weights larger than 0.15 g. From industrial experience, it is known that a high amount of small type I chips will lead to a good chip breakability. The results from the machining test show that the fraction of type I chips from machining of the 157REM steel (65 %) is smaller than from machining of the 157C reference steel (80 %) when using a lower feed rate of 0.4 mm/rev. However, when using a higher feed rate of 0.5 mm/rev, 40 % of the chips belong to type I small chips for the 157REM steel and 14 % for the 157C steel. Based on the conditions used in this study and the obtained results, the following is clear in order to reach the best machinability: i) it is most advantageous to use the 157C steel when using a lower feed rate of 0.4 mm/rev and ii) it is most advantageous to use the 157REM steel when using a higher feed rate of 0.5 mm/rev. / Närvaron av icke-metalliska inneslutningar (NMIs) har en betydande påverkan både med avseende på mekaniska egenskaper såväl som skärbarhetsförmågan hos stål. I denna avhandling är ett fokus att studera deformerade sulfider (MnS)  i ett rostfritt stål (3R65) och ett verktygsstål (42CrMo4). Tre grupper av MnS inneslutningar återfanns i stålproverna, som togs efter deformation av stålet: i) RS (sulfider som har en cylindrisk geometri), ii) PS (sulfider som har en platt geometri) och iii) OS (oxy-sulfider). Dessutom så studerades utdragna inneslutningar mer i detalj med användande av SEM undersökningar i syfte att studera tendensen till att dessa inneslutningar bröts sönder. Resultaten visade att tre typer av utdragna inneslutningar kunde identifieras, nämligen UU, UB och BB. Här representerar ‘U’ en ände av en inneslutning som inte brutits sönder och ‘B’ representerar en ände av en inneslutning som brutits sönder. Närvaron av dessa tre typer av utdragna inneslutningar studerades i prover som togs både före och efter en värmebehandling, men resultaten visade att en värmebehandling hade en mycket liten påverkan på morfologin hos de utdragna MnS inneslutningarna för både rostfria stål (innehållande <0.1 mass % C) och verktygsstål (innehållande 0.42 mass % C).  I den andra delen av avhandlingen så studerades karakteristiken hos spånor som bildats efter skärande bearbetning av ett 157REM (Ce-behandlat) modifierat stål och ett 157C referensstål som inte modifierats. Dessutom så studerades inverkan av icke-metalliska inneslutningar på spånbrytningen under den skärande bearbetningen. Resultaten visar att en Ce-modifiering av stålet omvandlar inneslutningarna från stora och utdragna geometrier till små inneslutningar med en sfärisk geometri. Detta leder till en ökad skärbarhet hos 157C stål. Spånbrytbarheten bestämdes också med användande av en nyutvecklad metod (WDC metoden) som baseras sig på att bestämma vikten av spånor. Resultaten av denna utvärdering visade att spånorna som erhölls från bearbetning av 157C och 157REM stål kunde klassificeras enligt följande tre typer: i) typ I spånor (en geometri som består av en bågform) som har en vikt som är mindre än 0.08 g, ii) typ II spånor (en geometri som består av två bågformar) som har en mellan 0.08 g och 0.15 g och iii) typ III spånor (en geometri som består av tre eller fler bågformar) som har en vikt som är större än 0.15 g. Baserat på industriell erfarenhet så är det känt att en stor mängd av små typ I spånor är kopplad till en bra spånbrytbarhet. Resultaten från skärbarhetstesterna visar att andelen typ I spånor från bearbetning av ett 157REM stål (65 %) är mindre än vid bearbetning av ett 157C referens stål (80 %), när en lägre matningshastighet av 0.4 mm/rev används. Däremot så visar resultaten att om en högre matningshastighet av 0.5 mm/rev används vid bearbetning, så är andelen typ I spånor 40 % för 157REM stålet och 14 % för 157C referensstålet. I syfte att erhålla bästa möjliga skärbarhet så är det fördelaktigt att använda ett 157C referensstål för den lägre matningshastigheten av 0.4 mm/rev, men att använda ett 157REM stål för en högre matningshastighet av 0.5 mm/rev.

In this article, James Frierson, J.D., outlines the requirements for group practices under the Americans with Disabilities Act (ADA). Rules concerning required changes take effect in January of 1993 (and sooner for some groups), making it imperative that group practices be aware of the new law.

OBJECTIVES: To model the frequency of 'last minute' cancellations of planned elective procedures in the English NHS with respect to the patient and provider factors that led to these cancellations. METHODS: A dataset of 5,288,604 elective patients spell in the English NHS from January 1st, 2007 to December 31st, 2007 was extracted from the Hospital Episode Statistics. A binary dependent variable indicating whether or not a patient had a Health Resource Group coded as S22--'Planned elective procedure not carried out'--was modeled using a probit regression estimated via maximum likelihood including patient, case and hospital level covariates. RESULTS: Longer waiting times and being admitted on a Monday were associated with a greater rate of cancelled procedures. Male patients, patients from lower socio-economic groups and older patients had higher rates of cancelled procedures. There was significant variation in cancellation rates between hospitals; Foundation Trusts and private facilities had the lowest cancellation rates. CONCLUSIONS: Further research is needed on why Foundation Trusts exhibit lower cancellation rates. Hospitals with relatively high cancellation rates should be encouraged to tackle this problem. Further evidence is needed on whether hospitals are more likely to cancel operations where the procedure tariff is lower than the S22 tariff as this creates a perverse incentive to cancel. Understanding the underlying causes of why male, older and patients from lower socio-economic groups are more likely to have their operations cancelled is important to inform the appropriate policy response. This research suggests that interventions designed to reduce cancellation rates should be targeted to high-cancellation groups.