###### Key messages

What is already known about this subject?
=========================================

-   Common mental disorders (CMDs) are among the main causes of sickness absence.

-   Brief work-directed interventions given by the occupational health service (OHS) to employees with CMDs have shown promising results concerning return to work (RTW).

What are the new findings?
==========================

-   In this cluster randomised study, a participative problem-solving intervention reduced sickness absence among employees with occupational stress or CMDs.

-   Symptoms of mental ill-health decreased in both the intervention and control groups during the 12-month follow-up period.

How might this impact on policy or clinical practice in the foreseeable future?
===============================================================================

-   Following a structured and participative problem-solving approach with early involvement of the employer may enhance the effects of work-directed interventions at the OHS.

-   Regular follow-ups of RTW plans developed by the OHS, the employee and the employer may facilitate RTW.

Background {#s1}
==========

Common mental disorders (CMD, ie, depression, anxiety and adjustment disorders) are among the main causes for (long term) sickness absence in many countries.[@R1] CMDs demand medical care consumption and they influence functioning and productivity of the individual. In the EU, one in six people had a mental health problem in 2016,[@R2] leading to an estimated total cost of over 600 billion Euros per year whereof indirect costs, such as absenteeism and presenteeism, constitutes the largest part.[@R2] Against this background, the need for effective interventions related to work ability is called for.

Studies have found that the combination of high job demands with low levels of control at work can increase the risk for CMD,[@R3] while organisational justice and influence at work can decrease the risk.[@R4] When problems in the work environment contribute to the development of CMD, changes in the work environment (eg, change of responsibilities/assignments; change in work schedule) become important to reduce CMD, and consequently also sickness absence. Interventions or treatments on an individual, group and/or organisational level can help to reduce the risk for continued CMD problems and (new) periods of sickness absence. Adding a work-directed approach to a clinical intervention can be effective in improving work return or decreasing sickness absence.[@R6] The aim of work-directed interventions is to facilitate work return, or maintain work ability and/or to help the employee to manage his/her psychiatric symptoms in relation to work.[@R6] Several studies compared care as usual (CAU) with work-directed interventions for employees on sick leave due to CMD.[@R7] In some studies, partial return to work (RTW) was accelerated by the work-directed interventions compared with CAU. However, the results concerning full-time RTW did not show that work-directed intervention was better than CAU.[@R8] Work-directed interventions for improving RTW may also help to prevent future sickness absence for employees that are currently at work but are at risk of future sickness absence due to mild to moderate mental problems or occupational stress.[@R13]

The occupational health service (OHS) exists in most industrialised countries. It aims to support employers in promoting employee health.[@R14] The OHS is also an important actor for rehabilitative measures among employees on sick leave as well as early prevention offered to employees with symptoms of poor health in the workplace.[@R15] OHS has knowledge of the employee's work environment and can offer interventions to prevent sickness absence that take into account both the individual and the workplace.

In this study, we evaluated the effects on sickness absence, RTW and mental health of a work-directed intervention given by the OHS to employees with CMDs or stress-related symptoms at work.[@R16] The hypothesis for the primary outcome was that the intervention should reduce sickness absence compared with CAU.

Methods {#s2}
=======

Study design and setting {#s2-1}
------------------------

The study was a two-armed cluster randomised controlled design with a 1 year follow-up period. It was conducted in collaboration with three OHS (four units) in Sweden. The design and procedures of the study has been reported in detail in the study protocol,[@R16] but a brief summary will be presented below.

Inclusion and exclusion criteria {#s2-2}
--------------------------------

Inclusion criteria were as follows:

-   The employee sought help at the OHS for a new episode of occupational stress or symptoms related to CMDs affecting the ability to work. If the employee was on sick leave due to CMDs this period should not have exceeded 3 months.

-   The employee should agree to the involvement of the employee's manager in the intervention.

-   The employee had to understand both written and spoken Swedish.

Exclusion criteria were pregnancy, victim of workplace bullying, post-traumatic stress disorder or other severe mental illness or co-morbidity.[@R16]

Recruitment of participants {#s2-3}
---------------------------

Recruitment occurred between August 2015 and June 2017, in cooperation with the participating OHS. After receiving information about the study and being trained in the recruitment process, consultants recruited employees. The research group contacted the recruited employees to give them more detailed information and to obtain written consent. Further, the employee received the baseline questionnaire, in which receipt of the information about the study had to be confirmed. Study inclusion occurred on returning the completed questionnaire.[@R16]

Randomisation {#s2-4}
-------------

An independent statistician received lists of eligible OHS consultants and randomised them into the experimental treatment or CAU using computer-generated random numbers (conducted by LB). Randomisation was stratified by OHS unit and we randomised four more consultants to the experimental arm to compensate for recruitment problems at one of the units. See also [figure 1](#F1){ref-type="fig"}, [online supplementary table 1](#SP1){ref-type="supplementary-material"} and the protocol.[@R16]

10.1136/oemed-2019-106353.supp1

######

Employee characteristics per study group at baseline

  -----------------------------------------------------------------------------------------------
  Sociodemographic characteristics                            PSI\     CAU\
                                                              (n=41)   (n=59)
  ----------------------------------------------------------- -------- --------- ------- --------
  Age, years, m (SD)                                          42.66    (10.39)   44.00   (9.64)

  Female, n (%)                                               37       \(90\)    43      \(73\)

  Children, n (%)                                             23       \(56\)    39      \(66\)

  Education level, n (%)

   Primary/secondary education                                14       \(34\)    20      \(34\)

   Higher education/university                                27       \(66\)    39      \(66\)

  Work-private life balance, m (SD)

   Work influences private life                               3.20     (1.23)    3.42    (.91)

   Private life influences work                               1.98     (0.99)    2.27    (1.05)

  Employer, n (%)

   Municipality, county, state\*                              38       \(93\)    39      \(66\)

   Private business                                           3        \(7\)     20      \(34\)

  Ordinary working hours

   Full-time (40 h/week)                                      31       \(76\)    52      \(88\)

   Part-time (\<40 h/week)                                    10       \(24\)    7       \(12\)

  Presenteeism, n (%)

   No presenteeism                                            5        \(12\)    8       \(14\)

   Presenteeism (1 or more times)                             36       \(88\)    51      \(86\)

  HAD, n (%)

   Depression                                                 15       \(37\)    26      \(44\)

   Mild depression                                            8        \(20\)    16      \(27\)

   No depression                                              18       \(44\)    17      \(29\)

   Anxiety                                                    20       \(49\)    26      \(44\)

   Mild anxiety                                               13       \(32\)    25      \(42\)

   No anxiety                                                 8        \(19\)    8       \(14\)

  S-ED, n (%)

   Moderate/pronounced ED                                     31       \(76\)    40      \(68\)

   No ED                                                      10       \(24\)    18      \(31\)

  DCSQ, m (SD)

   Demand                                                     3.04     (0.55)    3.13    (.53)

   Control                                                    3.18     (0.36)    2.88    (.43)

   Support                                                    3.12     (0.60)    2.95    (.55)

   Stress, m (SD)                                             3.98     (0.89)    4.05    (.90)

   Production loss due to ill health, m (SD)                  6.20     (2.78)    6.51    (2.37)

   Production loss due to work environment problems, m (SD)   6.24     (3.22)    6.64    (3.15)

  Registered sickness absence†, n (%)

   No sickness absence                                        20       \(49\)    31      \(53\)

   Sickness absence                                           21       \(51\)    28      \(47\)

  Diagnoses‡, n (%)

   Reaction to severe stress, and adjustment disorders        17       \(41\)    24      \(41\)

   Other CMDs§                                                4        \(10\)    4       \(7\)
  -----------------------------------------------------------------------------------------------

\*Three individuals in PSI and seven employees in CAU were employed by the state.

†In Sweden, sickness absence benefits or disability pension is given for individuals with work-related income for 25%, 50%, 75% or 100% of the employee's ordinary working hours. The first 14 days of a sickness period, the employer pays approximately 80% of the daily wages of the employee. From day 15 to 90, the employer pays 10% and the SSIA approximately 80%. After 90 days employee compensation is received from the SSIA depending on degree of work ability.[@R37]

‡Data on diagnoses are obtained from register data from SSIA. Not all participating employees were on sick leave at baseline.

§Other anxiety disorders, single depressive episode and problems related to life management difficulty.

CAU, care as usual; CMD, common mental disorder; DCSQ, Demand Control Support Questionnaire; ED, Exhaustion Disorder; HAD, Hospital Anxiety and Depression scale; PSI, problem-solving intervention; S-ED, self-reported exhaustion disorder; SSIA, Swedish Social Insurance Agency.

Blinding {#s2-5}
--------

Employees were blinded to the possibility of receiving another intervention within the trial. Consultants were not blinded regarding which treatment was given.[@R16] The statistician and the researchers were blinded at the initial analysis of the primary outcome but not, due to practical reasons, during the entire process of analyses.

The problem-solving intervention (PSI) {#s2-6}
--------------------------------------

The OHS consultants received a 1-day training course by members of the research group and a clinical psychologist.[@R16] They also received detailed work sheets. The focus of the intervention was primarily on adjusting the work situation and secondarily to give the employee advice concerning stress management. The goal was promotion of work ability and RTW. The theoretical basis for the intervention stems from problem-solving therapy,[@R12] and the 'mismatch' model concerning the match between the employee and the work environment. It emphasises six aspects of the work situation which are addressed during the meetings (ie, workload, control, reward, community, fairness and values).[@R17] In the first two steps of the intervention, the consultant interviewed the manager and the employee, respectively. The third step consisted of a joint meeting in which a participatory approach was applied by which the employee's manager and the employee were guided by the consultant and encouraged to actively take part in problem solving concerning the work situation.[@R18] At least three follow-ups of the manager and the employee during a 3-month period were recommended.

Care as usual {#s2-7}
-------------

The consultants randomised to CAU received a general introduction in research about psychosocial factors and mental health at work for approximately 1 hour. CAU at the participating OHS implied that both employee and manager usually were involved in the intervention. CAU was neither structured to the same degree as PSI nor based on the same theoretical frameworks.[@R16] However, CAU was also work-directed.

Procedure {#s2-8}
---------

Registered data on sickness absence was obtained from the Swedish Social Insurance Agency (SSIA). Questionnaires were administered at baseline, after 6 months and after 12 months. Since the first 14 days of a period of sickness absence (ie, short-term sickness absence) are not covered by the SSIA, SMS messages were sent to the participants every fourth week over the follow-up period, to gather information about all sickness days during the follow-up year, including the first 14 days. SMS as data collection method has shown to be feasible.[@R20]

Dependent variables {#s2-9}
-------------------

### Primary outcome {#s2-9-1}

#### Registered sickness absence {#s2-9-1-1}

The primary outcome was total number of days of registered sickness absence (sickness benefit and disability pension), defined as the total number of net absence days (all causes) during the 12-month follow-up period.

### Secondary outcomes {#s2-9-2}

#### Self-reported sickness absence, RTW and production loss {#s2-9-2-1}

Questions were sent to the participants concerning sick leave and days of sickness absence over the last 4 weeks,[@R21] ordinary working hours,[@R16] production loss due to ill health or work environment problems[@R23] and stress[@R24] ([online supplementary table 2](#SP2){ref-type="supplementary-material"}).

10.1136/oemed-2019-106353.supp2

For those with sickness absence at baseline, partial RTW was calculated as the time from baseline until the employee returned to work in any increased capacity. Full RTW was defined as working ordinary hours over an uninterrupted period of at least 4 weeks.

#### Mental/general health, sleep and work ability {#s2-9-2-2}

See [online supplementary table 3](#SP3){ref-type="supplementary-material"} and the protocol,[@R16] for an overview of the questionnaires used to measure depression, anxiety,[@R25] exhaustion,[@R26] general health and sleep problems,[@R28] presenteeism,[@R4] work ability,[@R31] job satisfaction[@R32] and psychological and social aspects at work.[@R3]

10.1136/oemed-2019-106353.supp3

Data analysis {#s2-10}
-------------

The analyses were conducted as intention-to-treat analyses and run by IBM SPSS statistics V.25.

Baseline variables with a potential impact on the outcome that were deemed to have been unevenly distributed between the experimental and the control condition were added as potential confounders in the analyses. These confounders were considered based on statistical significance and/or clinical significance.

To investigate the primary outcome, registered days of sickness absence, we performed general estimated equations (GEE) using an independent correlation structure and robust variance estimation. Parameter estimates, standard errors and the correlation information criterion were checked for independent and exchangeable correlation structures.

The analyses were conducted in two steps. In step 1, only the outcome variable was analysed concerning its development from baseline and during follow-up to check for potential time, group and time × group effects. In the second step, we checked for potential interaction effects based on gender × group and sickness absence at baseline × group (no sickness absence vs sickness absence).

GEE analyses were also employed to analyse self-reported days on sickness absence, stress and production loss due to ill health or work environment problems.

Cox regression was used to investigate group differences in time to full and partial RTW. In the analyses with Cox regression, only individuals that were on sick leave (part-time or full-time) at baseline were included. Group differences regarding mental health, quality of life, two items of work ability and job satisfaction were analysed with multivariate analysis of variance (ANOVA). We used an alpha of \<0.05 to indicate statistical significance.

Results {#s3}
=======

[Figure 1](#F1){ref-type="fig"} shows that 137 employees were recruited (mean=3.7 per consultant) of which 100 were included in the study. The mean age of the excluded employees was 41.2 years and seven were male.

![Flow diagram showing the recruitment of consultants, experimental and control groups. OHS, occupational health service.](oemed-2019-106353f01){#F1}

In PSI, most employees (73%) completed the three steps within 6 weeks after baseline. In CAU, 39 employees also had a joint meeting, of which 37 completed it within 6 weeks after baseline.

[Table 1](#T1){ref-type="table"} shows the baseline characteristics of the participants in both groups. The distributions of the different baseline characteristics were similar (based on t-test and Mann-Whitney U test) for both groups for all variables except for the variable 'employer' (p\<0.001), 'gender' (p=0.023) and the 'control' dimension of the Demand Control Support Questionnaire (p\<0.001). These variables were controlled for in the primary analyses.

Response rate {#s3-1}
-------------

At 6 months and 12 months after baseline, response rates were 86% and 84%, respectively. In total, 6500 SMS messages were sent to the participants (5 questions × 13 periods × 100 participants). Mean response rate for PSI was 93.6%. For CAU, mean response rate was 90.3%.

Primary outcome: registered sickness absence {#s3-2}
--------------------------------------------

Initially, analyses of disability pension were also planned. However, since none of the participants received disability pension, during the 12-month follow-up, the data only include sickness absence.

Among the employees that received PSI, 15 persons (36.6%) had no registered sickness absence at all during the follow-up. Among the employees receiving CAU, this number was 22 (37.3%). [Figure 2A](#F2){ref-type="fig"} shows the actual course of registered sickness absence over the 12 months before baseline and the follow-up period. [Figure 2B](#F2){ref-type="fig"} depicts estimated second-degree regression curves for the follow-up period for CAU and PSI. Both groups have a similar course of sickness absence until baseline ([figure 2A](#F2){ref-type="fig"}). During the follow-up, PSI has a different course of sickness absence compared with CAU with fairly equal absence at the start and at the end of the period but a pronounced difference at the middle of the period, ie there is a case of statistical interaction between group and time. This interaction revealed to be statistically significant (p=0.033). To give a more detailed picture of the course of sickness absence, [table 2](#T2){ref-type="table"} shows the estimated mean differences in sickness absence for each group per month. Statistically significant differences were found for months 5--8. In total, the difference in estimated sickness absence days during these months was almost 15 days, to the advantage of PSI. No interaction for gender × group was found (p=0.242).

![(A) Actual course for registered sickness absence per month 1 year before and 1 year after baseline for PSI and CAU. (B) The course for registered sickness absence per month over the follow-up year for PSI and CAU as estimated by the GEE analysis. Note that the days reported in this figure concern the days that exceed the first 14 days of a sickness absence period, as the first 14 days are not registered by the SSIA. CAU, care as usual; GEE, general estimated equation; PSI, problem-solving intervention; SSIA, Swedish Social Insurance Agency.](oemed-2019-106353f02){#F2}

######

Descriptive figures show mean days and SD for each group per month for sickness absence during the follow-up period ([figure 2A](#F2){ref-type="fig"}). Estimated mean differences in sickness absence for each group per month. The estimated values correspond to the regression model in [figure 2B](#F2){ref-type="fig"}.

  Month                           Baseline   1        2        3        4        5        6        7        8       9       10      11      12
  ----------------------- ------- ---------- -------- -------- -------- -------- -------- -------- -------- ------- ------- ------- ------- -------
  *Descriptive figures*
   Mean days              PSI     11.3       11.9     9.3      7.2      6.0      5.2      5.1      4.3      3.5     3.2     2.3     3.6     3.0
   (SD)                           (12.6)     (13.1)   (11.6)   (10.6)   (9.8)    (8.3)    (8.2)    (8.3)    (7.5)   (7.2)   (6.2)   (8.6)   (8.2)
   Mean days              CAU     10.6       13.6     11.9     10.6     10.1     9.5      8.8      7.4      6.6     5.6     4.7     4.4     3.9
   (SD)                           (12.5)     (13.0)   (12.9)   (12.5)   (12.1)   (11.7)   (11.1)   (10.3)   (9.3)   (8.9)   (8.6)   (8.5)   (8.5)
  *Estimated Figures*
   Mean days              PSI     12.2       10.5     9.0      7.7      6.5      5.5      4.7      4.0      3.5     3.2     3.0     3.0     3.09
  CAU                     12.4    11.9       11.3     10.7     10.0     9.3      8.6      7.8      7.0      6.1     5.2     4.2     3.24
   Mean difference        −0.2    −1.4       −2.3     −3.0     −3.5     −3.8     −3.9     −3.8     −3.5     −2.9    −2.2    −1.3    −0.14
   95% CI                 Lower   −5.4       −5.9     −6.5     −7.0     −7.4     −7.6     −7.6     −7.3     −6.8    −6.1    −5.3    −4.3    −3.38
  Upper                   4.9     3.2        1.9      1.0      0.4      0.0      −0.2     −0.2     −0.1     0.3     0.8     1.8     3.10

CAU, care as usual; PSI, problem-solving intervention.

The course of sickness absence during the follow-up differed between employees that were on sick leave at baseline and employees that were not. This interaction between sickness absence at baseline, group and time also revealed to be statistically significant (p\<0.001). The same pattern emerged as in the primary analysis; PSI consistently had less sickness absence than CAU regardless of whether the employees were on sick leave or not at baseline (although not statistically significant, reasonably due to the lower statistical power in these analyses that concerned more factors in the model). OHS service was added as a potential confounder, and then the estimated difference between PSI and CAU increased on average by 0.31 days per month during the follow-up period. Employer sector and control at work were unevenly distributed across interventions; however, they did not influence the effect parameter when included as potential confounders in the analytic models.

Secondary outcomes {#s3-3}
------------------

### Self-rated sickness absence, RTW, stress and production loss. {#s3-3-1}

The number of self-reported sickness absence days during the follow-up period was also lower for PSI compared with CAU ([online supplementary figure 1](#SP4){ref-type="supplementary-material"}), but there was no statistically significant interaction between group and time (p=0.162).

10.1136/oemed-2019-106353.supp4

A total of 88% in PSI and 76% in CAU had fully returned to work 12 months after baseline, (HR=1.54; 95% CI=0.78; 3.03). PSI had a statistically significant earlier partial RTW compared with CAU (100% partial RTW after 5 respectively 8 months; HR=1.93; 95% CI=1.05; 3.56) (see [online supplementary figure 2](#SP5){ref-type="supplementary-material"}).

10.1136/oemed-2019-106353.supp5

For stress, production loss due to ill health and production loss due to work environment problems, there was a statistically significant improvement over time (p=0.001, p\<0.001 and p=0.001, respectively), but no statistically significant interactions between group and time (p=0.973, p=0.924 and p=0.462, respectively) were found.

### Mental/general health, sleep and work ability {#s3-3-2}

According to [table 3](#T3){ref-type="table"}, the intervention had no statistically significant effect compared with CAU on mental health and stress-related symptoms except for self-perceived general health at 6 months. PSI reported a better general health compared with CAU. There were no statistically significant differences between groups on the ordinal variables self-reported exhaustion disorder (S-ED) and presenteeism, nor for employees' own prognosis of their work ability in 2 years' time.

######

Mean values (SD) for mental health and stress-related symptoms over time based on raw data. Mean differences between groups calculated with multivariate ANOVA\* with baseline as covariate are given in the two columns to the right

                                  Mean values† (SD)   Baseline 6 months   Baseline 12 months
  ------------------------------- ------------------- ------------------- -------------------- ------------------------ -----------------------
  HAD---depression
   PSI                            9.00 (4.04)         7.71 (4.44)         6.57 (3.93)          1.14 (−0.53; 2.82)       −0.23 (−1.81; 1.36)
   CAU                            9.87 (4.61)         7.03 (4.40)         7.04 (3.83)
  HAD---anxiety
   PSI                            10.88 (4.31)        9.26 (4.10)         8.79 (4.38)          0.74 (−0.74; 2.21)       0.84 (−0.94;2.62)
   CAU                            11.22 (3.99)        9.08 (3.80)         7.88 (3.99)
  MBI---exhaustion
   PSI                            4.18 (1.54)         3.72 (1.68)         3.55 (1.55)          0.23 (−0.39; 0.84)       \<−0.01 (−0.58; 0.58)
   CAU                            4.23 (1.46)         3.77 (1.68)         3.50 (1.58)
  KSQ sleep quality
   PSI                            3.26 (1.37)         3.58 (1.27)         3.62 (1.19)          −0.28 (−0.74;0.18)       −0.11 (−0.56; 0.33)
   CAU                            3.36 (1.27)         3.86 (1.26)         3.86 (1.22)
  EQ5D
   PSI                            71.18 (20.55)       74.34 (19.27)       76.28 (19.01)        −4.46 (−12.68; 3.77)     −1.63 (−9.97; 6.71)
   CAU                            68.33 (22.49)       76.58 (18.84)       77.62 (20.20)
  Self-perceived general health
   PSI                            3.44 (0.90)         3.53 (0.86)         3.29 (0.91)          **0.37 (0.002; 0.73**)   0.18 (−0.18; 0.54)
   CAU                            3.22 (1.15)         3.11 (0.91)         3.00 (0.90)
  Work ability---physical‡
   PSI                            3.63 (1.11)         3.88 (0.91)         4.00 (1.06)          −0.12 (−0.60; 0.37)      −0.11 (−0.52; 0.30)
   CAU                            3.95 (0.97)         3.83 (1.14)         4.02 (0.94)
  Work ability---psychological‡
   PSI                            2.75 (1.03)         3.29 (0.91)         3.75 (0.88)          0.11 (−0.34; 0.55)       −0.23 (−0.62; 0.17)
   CAU                            2.74 (1.19)         3.34 (1.16)         3.54 (1.09)
  Job satisfaction
   PSI                            6.34 (2.12)         6.29 (2.47)         6.88 (1.98)          −0.55 (−1.56; 0.46)      0.15 (−0.79; 1.10)
   CAU                            6.20 (2.33)         6.52 (2.45)         6.62 (2.57)

Bold numbers: p\<0.05.

\*Non-response in multivariate ANOVA was approximately 20% for CAU. It varied between 29% and 22% for PSI.

†The mean values given here are for all participants responding at the follow-ups.

‡Items included in the Work Ability Index.

ANOVA, Analysis of Variance; CAU, care as usual; EQ5D, European Quality of Life 5-Dimensions Questionnaire; HAD, Hospital Anxiety and Depression Scale; KSQ, Karolinska Sleep Questionnaire; MBI, Maslach Burnout Inventory; PSI, problem-solving Intervention.

Statistically significant time effects within both groups were found for depression, anxiety, exhaustion, S-ED, presenteeism and estimation of work ability with respect to psychological demands. See [online supplementary tables 4 and 5](#SP6 SP7){ref-type="supplementary-material"} for more details.

10.1136/oemed-2019-106353.supp6

10.1136/oemed-2019-106353.supp7

Discussion {#s4}
==========

The aim of this study was to evaluate the effectiveness of a work-directed intervention given by the OHS to employees with CMDs or stress-related symptoms on sickness absence, RTW and mental health. The primary result showed a statistically significant interaction between time and group, and the estimated net days of registered sickness absence were approximately 15 days lower for PSI than for CAU during follow-up. Furthermore, participants on sickness absence displayed a significantly faster partial RTW for PSI compared with CAU, but no significant differences between groups were detected concerning full RTW. No significant differences were found between PSI and CAU regarding self-reported sickness absence that also included short-term sickness absence. Mental health improved in both groups, but no group differences were found.

Directly after baseline, registered sickness absence increased in both groups, especially in CAU. An explanation might be that high levels of psychological symptoms at baseline caused many participants to take sick leave or to increase the degree of sickness absence.[@R34] This may have been subdued by the emphasis on work return or maintaining work in the experimental group.

According to the treatment manual, consultants that delivered PSI should offer at least three follow-up meetings with the employees, preferably during the 12 weeks after the joint meeting. These follow-up meetings might explain the increasing difference in sickness absence between PSI and CAU during the first period of the 12-month follow-up. After the last follow-up meeting, the effect of these meetings might have attenuated which may explain why the difference in sickness absence between PSI and CAU declines during the second part of the 12-month follow-up period. Follow-up meetings were offered in CAU as well, but the content, structure and implementation of these follow-up meetings were not specified. The relation between the follow-up meetings and registered sickness absence will be investigated in a forthcoming process analysis.

The results concerning a faster partial RTW in the PSI group, but no faster full RTW, are in line with earlier studies.[@R8] This indicates that PSI facilitates RTW but also that it might benefit from, and be more effective, if it was more comprehensive.

In both groups, symptoms of depression, anxiety and exhaustion were significantly reduced during follow-up, but no differences between groups were found, except for general health. It is not clear to what degree the within-group effects are an effect of treatment or of natural recovery, because all participants received treatment. The level of the symptoms score at the 12-month follow-up indicates that there is clearly room for further improvement both for PSI and CAU. Despite the similar course in symptom reduction for both groups, the PSI group decreased their sickness absence to a higher degree, which appear to support earlier findings that psychological symptoms and RTW are at least partially independent from each other and that work return need to be addressed specifically.[@R8]

Since sickness absence due to CMDs is a major challenge in many countries,[@R1] the results should be of interest from an international perspective. Both the OHS perspective and the content and design of the intervention were inspired by earlier work from the Netherlands.[@R8] Since our results in general are in line with results from these studies, there appear to be some generalisability across countries and OHS contexts.[@R14]

Methodological considerations {#s4-1}
-----------------------------

A strength of this study is the randomised controlled design and the blinding of participants concerning the treatment condition they adhered to. Furthermore, the primary outcome sickness absence was gathered from public registers and the response rates on the self-report measurements were high. Further, the participants were recruited from OHS across different parts of Sweden to primarily enhance the generalisability of the results to the Swedish context.

In [table 2](#T2){ref-type="table"}, where the course of the primary outcome sick leave days during the follow-up period was specified, multiple significance tests were done, and these results should be interpreted with caution due to the risk of type I error.

The study did not reach the planned size of the population, which was 150 participants. This brings a lack of statistical power and increases the risk of type II errors and the risk that actual differences between PSI and CAU are missed out. Since 80% of the study population consisted of women it is also unclear if the results are relevant for men.

The study was originally designed to include only employees on sickness absence due to CMDs; however, the recruitment became very slow by using this criterion. Consequently, to be able to finish the study within the planned time frame, the inclusion criteria were widened also to accept employees still at work who sought help for stress symptoms or CMDs at the OHS. As mentioned in the results, PSI descriptively showed less days on sick leave compared with CAU also among those not on sick leave at baseline; however, statistical analyses were not meaningful to do due to lack of statistical power. Furthermore, a larger number of participants were recruited to CAU than to PSI. Due to organisational reasons at one of the participating OHS the consultants were not given some extra resources at the start of the study they were asking for. Therefore, very few employees were recruited by these consultants. This issue was not evident at any of the other three OHS units. Finally, the risk of selection bias cannot be excluded as it was the consultants that invited employees for the study.

Consultants in CAU received a 1 hour lecture on psychosocial factors and mental health and this was not considered to have any important impact on the content of the CAU intervention since it did not include any specific techniques, or recommendations, on how to decrease sickness absence among employees. The focus in this report is on registered sickness absence. The secondary analyses are explorative and a complement to the primary analyses. For that reason, we have not discussed all secondary outcomes in detail.

Implications {#s4-2}
------------

There has been some evidence that work-directed interventions with problem-solving strategies are effective in promoting RTW and in decreasing the length of sickness absence. This study expands this evidence as it indicates that a work-directed intervention with a problem-solving strategy is more effective compared with CAU in decreasing sickness absence among employees with CMDs or stress-related symptoms at work. A reduction in sickness absence may also reduce costs for the employer, the employee and society at large. A forthcoming study will explore the cost-effectiveness of the intervention and a process analysis will establish more details about the implementation of the intervention at the OHS.

We would like to express our gratitude to our contact persons and the occupational health service (OHS) consultants at the participating OHS units. We are grateful for the support for the study from the Centre for Occupational and Environmental Medicine, Stockholm County Council.

**Contributors:** GB is the principal investigator of the research project and had the main responsibility for the design and all other parts of the study, the writing of the manuscript and acquiring of funding for the study; MKvdP contributed to the content of the manuscript, outlined and wrote the manuscript with continuing support from GB and conducted the analyses on the secondary outcomes with support from JH and GB. LN was involved in designing the recruitment process and both LN and CL coordinated the entire project; JH conducted the statistical analyses on the primary outcome and contributed to the secondary outcomes. LB has made substantial contributions to the design of the study and carried out the power calculations; LK and ML-K have made important contributions to the design and content of the different parts of the study; IJ has made important contributions to the design of the study and gave input on the intervention. MT has made important contributions to the eligibility criteria and gave input on the design of the study. All authors have made a substantial contribution to the manuscript's design and conception, the acquisition of data and interpretation of data. All authors have substantially revised the manuscript critically for important content. All authors discussed the results and commented on the manuscript.

**Funding:** Primary sponsor: The Swedish Research Council for Health, Working Life and Welfare (registration number 2014-0742). Secondary sponsor: The Swedish Social Insurance Agency (registration number 027552-2015).

**Competing interests:** None declared.

**Patient consent for publication:** Not required.

**Ethics approval:** Ethical approval, including how consent to participate was gathered, was granted by the Ethical Review Board in Stockholm (registration number 2015/549-31/1). Eligible employees received verbal and written information from the occupational health service (OHS) consultant about the study and those employees preliminary interested to participate gave written consent to transfer contact information from the OHS unit to Karolinska Institute (KI). Final consent was obtained, and study inclusion achieved, when the employee confirmed having taken part of detailed information about the study, both in writing and verbally, by ticking a box at the end of the baseline questionnaire and submitted the questionnaire to KI.

**Provenance and peer review:** Not commissioned; externally peer reviewed.

**Data availability statement:** The data sets used and analysed during the study are available from the corresponding author on reasonable request and after ethical approval from the Swedish Ethical Review Authority.


Inner strength in women with chronic illness.
Objectives This literature review summarizes research relevant to the meaning of inner strength in females living with a chronic illness. This review also examined studies that have used The Inner Strength Questionnaire to examine inner strength among chronically ill females. Methods Using the search terms inner strength and women, CINAHL, PubMed, and ProQuest Nursing databases were searched for the years 1990-2016. Ten articles met the inclusion criteria. Results Inner strength in women is a mental health construct that women can encompass to positively affect their quality of life while living through challenging life events. The Theory of Inner Strength appears to be a useful a framework for understanding how physical, psychological, and spiritual health can promote well-being, quality of life, and spirituality in women. Discussion The limited number of studies identified suggests the need for further investigations to explore the relationship between inner strength and quality of life among females living with chronic health conditions. The Inner Strength Questionnaire is a unique tool with adequate psychometric properties to measure inner strength in chronically ill women that includes a holistic assessment of living with a chronic illness that encompasses women' social, physical, emotional, and spiritual needs.


Senate Majority Leader Harry Reid’s passion for his hometown of Searchlight, Nev., might be matched only by his scorn for the Koch brothers. But on Monday, Mr. Reid announced that he and his wife, Landra, had sold their home in Searchlight to move closer to their four children and 16 grandchildren near Las Vegas.

The Reids sold their home, roughly 110 acres of land, eight mining claims and both mineral and water rights to Nevada Milling and Mining for $1.7 million, according to the lawmaker’s office. The company is expected to develop a gold mine in the area.

Mr. Reid was born in Searchlight, a mining town with a population of 539 in the 2010 Census, and had lived there with his wife for 25 years. But the Reids felt that new gold-mining operations were being conducted too close to their home, his office said. The couple will continue to own a piece of land in Searchlight. but are now looking to purchase a residence near Las Vegas, roughly 60 miles north, to be closer to their family and shorten Mr Reid’s travel time during his next re-election campaign in 2016.

“I’ve got a re-election coming up and I’ve been in a few elections commuting from Searchlight and it’s hard, so this will make that part of it much easier,” Mr. Reid said in a video released Monday.

Mr. Reid has written two books involving Searchlight: a history of the town called “Searchlight: The Camp That Didn’t Fail” and a memoir called “The Good Fight: Hard Lessons from Searchlight to Washington.”

During his childhood in the desert town, Mr. Reid would entertain himself by counting cars on the two-lane highway leading to Las Vegas, he said in the video.

“Why? Something to do,” he said. “We did things that wouldn’t be much fun for other kids.”

About Washington Wire

Washington Wire is one of the oldest standing features in American journalism. Since the Wire launched on Sept. 20, 1940, the Journal has offered readers an informal look at the capital. Now online, the Wire provides a succession of glimpses at what’s happening behind hot stories and warnings of what to watch for in the days ahead. The Wire is led by Reid J. Epstein, with contributions from the rest of the bureau. Washington Wire now also includes Think Tank, our home for outside analysis from policy and political thinkers.


Miscellaneous

If you are like me, you love the old C1930-50 hand made one-of-a-kind Raggedy Ann and Andy dolls that were made by mothers everywhere. McCall published a pattern in 1940 with instructions to make a 19" doll. But hand made Raggedy dolls were made by mothers even before that. Each and every one is unique and has its own personality and look. I am a doll dealer and I did not intend to seek out Raggedy Ann and Andy, but they more or less sought me out. I would buy ones that I found and put them away. In some cases, my purchases were a pathetic mercy purchase to give the dolls a home. I am now listing those dolls. For reference to these dolls, please see The Raggedy Ann and Andy Family Album by Susan Ann Garrison pages 65-68.

None of the dolls I list are in mint condition as Raggedy dolls were meant to be dragged everywhere and loved by the children they were sewn for. For the most part, the dolls were made from materials, mostly cottons, that mother had around the house. Many times the hands are stained from going in mouths and sucked upon. The floppy nature of the bodies lent themselves to be torn or soiled just like Raggedy Ann and Andy in the Johnny Gruelle Raggedy Ann books. So you can expect to see staining, soiling, holes, rips and tears, mends, stretched elastic, missing parts of the outfits and general disrepair. Even hair color and style can be unique depending upon the whim of mother. The older ones appeal to me and tell a story of its life and the times it was made, and the sentiment and love that went into the creation. No two are alike. If you like mint new Raggedy dolls, there are plenty of them available. These old hand made gems are special and each one is unique from the expression on that ever smiling face to the clothing it is wearing.

This doll pair is from my grouping and they are a 20" well made C1940 Hand Made Raggedy Ann Andy Doll Pair that are Fabulous with large hands that I call lobster claw hands because of the prominent thumbs. This doll pair is great! The rag stuffed cotton bodies are appropriately clean with some aging and staining to the face and hands. You can tell these dolls are a pair by their matching blue and brown striped cotton seersucker legs. Also each doll has a wonderful RED felt heart with I Love You embroidered on it (very unusual). Each doll has full thick red wool yarn hair and both dolls are fresh smelling. Both dolls have the large hands and enlarged thumb with some staining and soiling from being held. There is a large stain on Anns face, the pantaloons match the apron with elasticized red stitching which has stretched, but amazingly the pantaloons waist is still holding up (some of the leg stitching has come apart at the hem). The great blue cotton dress is in very good shape with yellow and pink strung bead print with the sleeve elastic now stretched as you would expect. The apron does not have any age staining or yellowing. Andy has some fading to the blue cotton trousers, all the buttons on his shirt and trousers have decorative stitching (some minor stitching loss to the back of his shirt at the waist), the sailor cap is pinned to the back of his head, has black cotton feet,and has some stitching undone to the back of his left leg showing nylon hose stuffing. Both dolls have Great embroidered features with stitched black felt eyes, red felt nose, individual lashes, heart shaped mouth and eyebrows. They are pretty wonderful!

1. You can call me at (413) 774 3260 (9:00AM to 9:00PM Eastern Standard Time) and you can purchase the item over the phone directly with me.

2. You can email me at giving a brief description or item number of the item that you would like to purchase. In your e-mail, please include your name, address and state including the zip code, where you would like the item to be shipped so actual shipping charges can be calculated. I will respond to your e-mail with the total purchase price including shipping and sales tax (if applicable). If you would like to include your telephone number, that would be helpful as well. Please allow up to 24 hours for my response.

3. You can click the PayPal "BUY NOW" button at the bottom left of each item page. You can pay directly and instantly from your PayPal account. The link takes you safely and securely to PayPal. You know you are at a secure PayPal site when you see the green PayPal bar in the www.paypal.com URL placement. Shipping amount has already been calculated and you can conveniently pay upon purchase. I will receive notification that you have purchased and paid for the doll. The buyer pays all shipping costs. If there is a problem, please contact me. This is a commitment to purchase the item. PayPal payments are made to americanbeautydolls@comcast.net.

Other Purchasing Information

The shipping amount is not included in the listed price and is additional. The buyer pays all shipping costs.

Combined shipping is available if you purchase several items at the same time. The shipping will be recalculated based upon weight. I will also partially refund shipping if there is a gross difference in paid and actual shipping amounts.

Payment is due when the item is purchased unless other arrangements are made with American Beauty Dolls.

I am also able to send you a PayPal invoice if that is your preference and is convenient for you. Invoices are sent using your email address.

All items are guaranteed as described. I am always happy to work with you in purchasing an item. Check back as I am adding items all the time!

Domestic Payment and Shipping

I accept PayPal, bank checks, or money orders with payment to arrive within 7 days. I also accept major domestic credit cards using SQUARE. I ship within 3 days of receiving cleared payment. PayPal payments are made to americanbeautydolls@comcast.net.

For Domestic purchases, I ship USPS Priority or Ground to make sure your purchase gets to you safely and quickly. The buyer is responsible for all actual shipping costs including shipping, handling, and insurance. All items are always carefully wrapped and packaged. The shipping amount is contingent upon the destination, weight and method of shipping.

Massachusetts residents must pay a 6.25% State Sales Tax or provide a signed copy of a valid Resale Form.

International Payment and Shipping

I ship to the United States ONLY.

NO International shipping.

NO shipping to a third party address.

NO shipping to any freight forwarding services or any re-shipping companies based in the United States with a US address. I will cancel those purchases. I will make NO exceptions.

Returns and Refund Policy

Any item purchased may be returned for any reason within three business days for a full refund. The buyer shall pay for the return shipping amount. Shipping fees are not refunded. Please notify me prior to shipping. The item must be returned in the same manner and in the same condition as sent to you. All my dolls are guaranteed to be as described.

Layaway Plan

A 60 day layaway plan is available. It includes 1/3 deposit down at time of purchase, 1/3 due within 30 days of purchase and the final payment due within 60 days of purchase. Of course, I expect you the buyer to follow through with the payment plan with timely payments. If a default is made, the layaway sale is cancelled, and I will refund money already paid minus a 15% restocking fee. A layaway plan is a courtesy offered to the buyer and must be approved first.

NRFB/NRFP: Never removed from the original package as it was made at the factory. Package may show some minor storage wear or age with the contents in mint condition.

MINT/PRISTINE: Just out of the package condition with the exception of factory manufacture flaws.

NEAR MINT: As close to being mint as an item can be for not being in the original package, but may have some flaws. Flaws would be minor and mostly due to the natural aging process (for instance fabric may have yellowed from age).

EXCELLENT: Condition appropriate for age and storage with some minor flaws described. No major flaws.

VERY GOOD: Condition appropriate for the age, and may have some flaws from gentle play, storage or display.

GOOD: The item has flaws from being handled and played with by a child with flaws described.

POOR: The item is being sold as-is and is as described, and may need restoration or repair. Or may be good for parts.

Payment Options

By PayPal:

By Check or Money Order:

If you wish to purchase a doll by check or money order please contact me at
giving a brief description or item number of the item that you would like to purchase. In your e-mail, please include your name, address and state including the zip code where you would like the item to be shipped so actual shipping charges can be calculated. I will respond to your e-mail with the total purchase price including shipping and sales tax (if applicable). If you would like to include your telephone number, that would be helpful as well. Please allow up to 24 hours for my response.


Q:

multiplicar div´s laço de repetição co div´s

Tenho uma lista de nomes de canais que estão transmitindo um determinado jogo na twitch.tv (api), sendo assim, consigo pegar todos os canais e listar os mesmos.
A dúvida é de como colocar-los em uma div Para ficar em blocos na horizontal (como na imagem) e também que, quando chegasse a 4 blocos (div´s), pulasse para a linha de baixo.
<?php

$api2 = file_get_contents("https://api.twitch.tv/kraken/search/streams?client_id=g5ynk8n0llmefg9m70ruyg36bbt6si&query=fifa17&limit=100");

$defuse = json_decode($api2);

if($defuse == null){
    echo "erro";

}else{

$total_lives=$defuse->_total;

echo "Toltal de Lives:  ".$total_lives."
";

    foreach($defuse->streams as $v)

    echo "Nome do Canal: ".$v->channel->name."
";

}
?>

`

A:

Uma boa alternativa é utilzar flexbox.

https://css-tricks.com/snippets/css/a-guide-to-flexbox/
https://tableless.com.br/flexbox-organizando-seu-layout/


Blacks In Congress Struggle To Maintain Influence

WASHINGTON - The political landscape changed dramatically in 2010 for Rep. Chaka Fattah, D-Pa., the audacious, skip-to-his-own-beat Philadelphia lawmaker hoping for tightened polls that evening — just enough to hold off an expected Republican takeover of the House.

His original plan was to embark on an ambitious, long shot bid for Chair of the powerful House Appropriations Committee, overseeing $1.4 trillion in discretionary funding and finding ways to push education as a top priority.

As the Grand Old Party amassed big gains that night, plans changed.

That didn’t really deter Fattah from his dream to run things on “Approps” as Capitol Hill rats affectionately abbreviate it. He simply went into minority ranking member mode, still intent on openly defying the Democratic Party’s Congressional seniority system.

Selection based on years served seemed like a simple formula long observed by Democrats. It worked to the favor of the quiet and senescent Rep. Norm Dicks, D-WA, who was next in line after retiring Appropriations Chair Rep. David Obey, D-WI.

Hopes for ranking member glory were dashed, however, when Fattah’s own Congressional Black Caucus gave the appearance of an endorsement for Dicks, who is White and has served in the House since 1976. It was a saddening and unexpected blow to Fattah, himself a longtime CBC Member.

“Members of the Congressional Black Caucus strongly support maintaining the seniority system for selecting committee leadership. The seniority system has served the Democratic Caucus well and has ushered in an era of diverse committee leadership, which is an asset to our party and our nation,” current CBC Chairwoman Rep. Barbara Lee, D-Calif., said in a statement released by POLITICO.

But, CBC spokesman J. Jioni Palmer disputes the authenticity of that statement. Dismissive of the reports and flatly denying any Caucus endorsement of Dicks, Palmer seemed annoyed by the question. “Reporters don’t know everything,” he retorted.

Still, observers argue that it makes sense, a shrewd and calculated move by the Caucus to ensure the integrity of the seniority system. Without it, many CBC Members wouldn’t have had their chance to chair influential committees: from Bennie Thompson, D-MI, on Homeland Security to Charlie Rangel, D-NY, formerly chairing Ways and Means.

The venerable Rep. John Conyers, D-MI, is still stone locked into Judiciary and Rep. Edolphus Towns, D-NY, held on as Chair of Government Reform. Turning on a native son to save the family seemed like an essential move since many CBC Members have been in the Congress long enough to assume an impressive number of leadership roles on influential committees.

At the end of the Democratic-led 111th Congress, there are four CBC House Committee Chairs and 18 subcommittee chairs. When Republicans take control in January, most — if not all — will transition into the Ranking Member role.

Fattah, however, was congratulatory in a statement on Dicks’ win. “I look forward to working with him and our colleagues on the Appropriations Committee to advance an agenda for the American people. I know that our leadership team, led by Norm, will be united as we head into the 112th Congress.”

And, in a conversation with the Tribune, he seemed pleased with his conciliation prize: ranking member of House Appropriation’s subcommittee on Commerce, Justice and Science, a decent look worth $70 billion in discretionary funding and a chance to transcend the urban politics typically associated with Philly’s most senior Congressional Member.

“Competition is a good thing,” said Fattah, particularly jovial that the controversial tax cut deal he endorsed in opposition to the CBC was about to pass.

But, the CBC remains in a state of constant, traumatic flux, struggling to regain or maintain influence on a scarred post-midterm battlefield. After weeks of uncertainty and a mountain of speculation, Towns suddenly withdrew himself from consideration as Ranking Member of the Government Reform Committee.


Yaqoub

Yaqoub is a 39-year-old, married man. He is a father to two sons and one daughter. He is employed and gets a low salary, which is not enough to cover the family's needs.

For the past three years, Yaqoub has been driving a taxi, which has been a profitable project and a good second source of income for the family. Yaqoub wants to own a taxi, to improve his earnings. Therefore he is requesting a USD Murabaha loan from FATEN, to help him cover the price of purchasing a new taxi. Owning the taxi will enable Yaqoub to work extra hours and to accept additional internal and external requests, which will improve the family's income positively. Yaqoub is photographed next to his taxi.

About Shariah-compliant lending:
FATEN offers loan products that are designed to serve borrowers all over Palestine, including some religiously conservative areas. A key tenet of Islam is the prohibition of interest in the lending or accepting of money. This prohibition is based on the belief that money should be seen only as a medium of exchange and that it has no value in itself. FATEN has adapted the terms of this loan to fit the cultural context by attaching a 0% interest rate to the loan. In order to cover its costs, FATEN does charge a servicing fee. The amount you see fundraising includes both the principal loan and the loan servicing fee. As with all Kiva loans, you should expect to have your funds returned to you in accordance with the repayment schedule attached to this loan. For more information on lending in the Muslim world, please visit Kiva's Muslim World Lending helptext: http://tinyurl.com/3aekx8m.

About FATEN

Palestinians face unique challenges due to the economic and political environment in the West Bank and Gaza. Click here to learn more about how Kiva and FATEN are working to help Palestinian borrowers overcome these obstacles and how your support can make a difference.


President Donald Trump speaks to the media before leaving the White House in Washington, Tuesday, Nov. 20, 2018, to travel to Florida, where he will spend Thanksgiving at Mar-a-Lago. (AP Photo/Manuel Balce Ceneta)

Trump defies calls to punish crown prince for writer’s death

The U.S. earlier sanctioned 17 Saudi officials suspected of being responsible for or complicit in the Oct. 2 killing, but members of Congress have called for harsher actions, including cancelling arms sales.

President Donald Trump has declared he will not further punish Saudi Arabia for the killing of U.S.-based columnist Jamal Khashoggi, making clear in an exclamation-filled statement that the benefits of good relations with the kingdom outweigh the possibility its crown prince ordered the killing.

The president condemned the brutal slaying of Khashoggi inside the Saudi consulate in Istanbul as a “horrible crime … that our country does not condone.” But he rejected calls by many in Congress, including members of his own party, for a tougher response, and he dismissed reports from U.S. intelligence agencies that Crown Prince Mohammed bin Salman must have at least known about such an audacious and intricate plot.

“It could very well be that the crown prince had knowledge of this tragic event,” the president said Tuesday. “Maybe he did and maybe he didn’t!”

In many ways, the statement captured Trump’s view of the world and foreign policy, grounded in economic necessity. It began with the words “America First!” followed by “The world is a very dangerous place!”

It came after weeks of debate over whether the president would or should come down hard on the Saudis and the crown prince in response to the killing of the Saudi columnist for The Washington Post who had criticized the royal family.

The U.S. earlier sanctioned 17 Saudi officials suspected of being responsible for or complicit in the Oct. 2 killing, but members of Congress have called for harsher actions, including cancelling arms sales.

Trump said “foolishly cancelling these contracts” worth billions of dollars would only benefit Russia and China, which would be next in line to supply the weapons. Critics, including high-ranking officials in other countries, denounced Trump’s statement, saying he ignored human rights and granted Saudi Arabia a pass for economic reasons.

Asked by a reporter if he was saying that human rights are too expensive to fight for, Trump responded, “No, I’m not saying that at all.” But then he switched the subject to the “terrorist nation” of Iran rather than any actions by Saudi Arabia.

The U.S. needs a “counterbalance” to Iran, “and Israel needs help, too,” he said. “If we abandon Saudi Arabia, it would be a terrible mistake.”

The mistake was Trump’s, said Republican Sen. Rand Paul of Kentucky, contending the administration has “blinders on” in comparing Iran and Saudi Arabia.

“It’s a sign of weakness not to stand up to Saudi Arabia,” Paul said. “Sometimes when you have two evils, maybe you don’t support either side.”

Republican Lindsey Graham, the South Carolina senator who is close to Trump, also disagreed with the president’s statement, saying America must not lose its “moral voice” on the international stage.

“It is not in our national security interests to look the other way when it comes to the brutal murder of Mr. Jamal Khashoggi,” Graham said.

Likewise, Rep. Adam Schiff, ranking Democrat on the House intelligence committee, said that to suggest that U.S. silence can be bought with arms sales “undermines respect for the office of the presidency, the credibility of our intelligence community and America’s standing as a champion of human rights.”

Trump’s statement, issued just before he pardoned the Thanksgiving turkey at the White House and left for the long holiday weekend in Florida, underscored his world view of putting U.S. interests — both financial and geopolitical — above all else.

He told reporters on the South Lawn that oil prices would “skyrocket” if the U.S. broke with the Saudis, and he was not going to “destroy” the world’s economy by being “foolish with Saudi Arabia.”

Asked about any personal financial involvement, he said: “Saudi Arabia has nothing to do with me. What does have to do with me is putting America first.”

Iran’s foreign minister, Mohammad Javad Zarif, mocked Trump’s announcement, tweeting that Trump “bizarrely devotes the FIRST paragraph of his shameful statement on Saudi atrocities to accuse IRAN of every sort of malfeasance he can think of.”

Zarif went on to joke that “perhaps we’re also responsible for the California fires, because we didn’t help rake the forests— just like the Finns do?” He appeared to be referring to recent remarks in which Trump suggested raking the forest floor prevented fires in Finland and would have helped to prevent California’s devastating wildfires.

Turkey’s foreign minister, Mevlut Cavusoglu, called Khashoggi’s killing “a humanitarian issue” and said it should not be covered up for the sake of maintaining trade ties with Saudi Arabia.

Trump said that King Salman and Crown Prince Mohammed both “vigorously deny” any knowledge of the planning or execution of the killing. He also said the CIA has not made a conclusive determination about whether the crown prince ordered it.

A U.S. official familiar with the case told The Associated Press last week that intelligence officials had concluded that the crown prince, the kingdom’s de facto leader, did order the killing. Others familiar with the case, however, have cautioned that while it’s likely the crown prince had a role there continue to be questions about the degree.

“We may never know all of the facts surrounding the murder of Mr. Jamal Khashoggi,” Trump said. “In any case, our relationship is with the Kingdom of Saudi Arabia. They have been a great ally in our very important fight against Iran.”

Saudi prosecutors say a 15-man team sent to Istanbul exceeded its authority when the lead negotiator in the team decided to kill Khashoggi for refusing orders to return. The Saudis say the agents dismembered his body, which has not been found.

Democrats on Capitol Hill called on the CIA and other top intelligence agencies to publicly report what it has learned about the killing.

The CIA had no comment on the president’s statement. However, former Director John Brennan, a frequent Trump critic, tweeted: “Since Mr. Trump excels in dishonesty, it is now up to members of Congress to obtain & declassify the CIA findings on Jamal Khashoggi’s death. No one in Saudi Arabia — most especially the Crown Prince —should escape accountability for such a heinous act.”

Trump said he knew some members of Congress would disagree with his decision. He said he would listen to their ideas, but only if they were focused on U.S. national security.

Late last week, a bipartisan group of senators introduced legislation that calls for suspending weapons sales to Saudi Arabia, for sanctions on people who block humanitarian access in Yemen or support the Houthi rebels, and mandatory sanctions on those responsible for Khashoggi’s death.

Democrats harshly criticized Trump’s decision Tuesday and called on Congress to cut off arms sales to Saudi Arabia and end support for Saudi Arabia’s war against the Iran-backed Houthi rebels in neighbouring Yemen, which is facing a humanitarian crisis.

“Standing with Saudi Arabia is not ‘America First!’” said Democratic Sen. Tim Kaine of Virginia, where Khashoggi lived. “President Trump has sided with a murderous regime over patriotic American intelligence officials.”

Democrat Dianne Feinstein of California, a member of the Senate intelligence committee, said Khashoggi was killed by agents of the Saudi government in a “premeditated murder, plain and simple,” and she said she would introduce legislation requiring intelligence agencies to release an unclassified public assessment.

Secretary of State Mike Pompeo defended Trump’s decision, saying, “We are determined to ensure that we continue to make sure that we take care of the American people in all of the strategic decisions we make about with whom we work with around the world.”

The president opened his eight-paragraph statement chastising Iran for its proxy war against Saudi Arabia in Yemen, its activities in Iraq, its backing of the Syrian government of Bashar Assad and its support of militant groups, which Riyadh has pledged billions to fight.


Primary Authors
===============

Yuri Takteyev <http://freewisdom.org/>, who has written much of the current code
while procrastingating his Ph.D.

Waylan Limberg <http://achinghead.com/>, who has written most of the available
extensions and later was asked to join Yuri, fixing nummrious bugs, adding
documentation and making general improvements to the existing codebase,
included a complete refactor of the core.

Artem Yunusov, who as part of a 2008 GSoC project, has refactored inline
patterns, replaced the NanoDOM with ElementTree support and made various other
improvements.

Manfed Stienstra <http://www.dwerg.net/>, who wrote the original version of
the script and is responsible for various parts of the existing codebase.

David Wolever, who refactored the extension API and made other improvements
as he helped to integrate Markdown into Dr.Project.

Other Contributors
==================

The incomplete list of individuals below have provided patches or otherwise
contributed to the project in various ways. We would like to thank everyone
who has contributed to the progect in any way.

Eric Abrahamsen
Jeff Balogh
Sergej Chodarev
Chris Clark
Tiago Cogumbreiro
Kjell Magne Fauske
G. Clark Haynes
Daniel Krech
Steward Midwinter
Jack Miller
Neale Pickett
John Szakmeister
Malcolm Tredinnick
Ben Wilson
and many others who helped by reporting bugs


Pickling (metal)

Pickling is a metal surface treatment used to remove impurities, such as stains, inorganic contaminants, rust or scale from ferrous metals, copper, precious metals and aluminum alloys. A solution called pickle liquor, which usually contains acid, is used to remove the surface impurities.  It is commonly used to descale or clean steel in various steelmaking processes.

Process

Metal surfaces can contain impurities that may affect usage of the product or further processing like plating with metal or painting. Various chemical solutions are usually used to clean these impurities. Strong acids, such as hydrochloric acid and sulfuric acid are common, but different applications use various other acids. Also alkaline solutions can be used for cleaning metal surfaces. Solutions usually also contain additives such as wetting agents and corrosion inhibitors. Pickling is sometimes called acid cleaning if descaling is not needed.

Many hot working processes and other processes that occur at high temperatures leave a discoloring oxide layer or scale on the surface. In order to remove the scale the workpiece is dipped into a vat of pickle liquor. Prior to cold rolling operation, hot rolled steel is normally passed through a pickling line so as to eradicate the scale from the surface.

The primary acid used in steelmaking is hydrochloric acid, although sulfuric acid was previously more common. Hydrochloric acid is more expensive than sulfuric acid, but it pickles much faster while minimizing base metal loss. The speed is a requirement for integration in automatic steel mills that run production at speeds as high as 800 ft/min (≈243 metres/min).

Carbon steels, with an alloy content less than or equal to 6%, are often pickled in hydrochloric or sulfuric acid. Steels with an alloy content greater than 6% must be pickled in two steps and other acids are used, such as phosphoric, nitric and hydrofluoric acid. Rust- and acid-resistant chromium-nickel steels are pickled traditionally in a bath of hydrofluoric and nitric acid. Most copper alloys are pickled in dilute sulfuric acid, but brass is pickled in concentrated sulfuric and nitric acid mixed with sodium chloride and soot.

In jewelry making, pickling is used to remove the copper oxide layer that results from heating copper and sterling silver during soldering and annealing. A diluted sulfuric acid pickling bath is traditionally used, but may be replaced with citric acid.

Sheet steel that undergoes acid pickling will oxidize (rust) when exposed to atmospheric conditions of moderately high humidity. For this reason, a thin film of oil or similar waterproof coating is applied to create a barrier to moisture in the air.  This oil film must later be removed for many fabrication, plating or painting processes.

Disadvantages
Acid cleaning has limitations in that it is difficult to handle because of its corrosiveness, and it is not applicable to all steels.  Hydrogen embrittlement becomes a problem for some alloys and high-carbon steels.  The hydrogen from the acid reacts with the surface and makes it brittle and causes cracks.  Because of its high reactivity with treatable steels, acid concentrations and solution temperatures must be kept under control to ensure desired pickling rates.

Waste products
Pickling sludge is the waste product from pickling, and includes acidic rinse waters, iron chlorides, and metallic salts and waste acid. Spent pickle liquor is considered a hazardous waste by the EPA. Pickle sludge from steel processes is usually neutralized with lime and disposed of in a landfill since the EPA no longer deems it a hazardous waste after neutralization. The lime neutralization process raises the pH of the spent acid. The waste material is subject to a waste determination to ensure no characteristic or listed waste is present. Since the 1960s, hydrochloric pickling sludge is often treated in a hydrochloric acid regeneration system, which recovers some of the hydrochloric acid and ferric oxide. The rest must still be neutralized and disposed of in land fills or managed as a hazardous waste based on the waste profile analysis. The by-products of nitric acid pickling are marketable to other industries, such as fertilizer processors.

Alternatives
Smooth clean surface (SCS) and eco pickled surface (EPS) are more recent alternatives. In the SCS process, surface oxidation is removed using an engineered abrasive and the process leaves the surface resistant to subsequent oxidation without the need for oil film or other protective coating. EPS is a more direct replacement for acid pickling. Acid pickling relies on chemical reactions while EPS uses mechanical means. The EPS process is considered "environmentally friendly" compared with acid pickling and it imparts to carbon steel a high degree of rust resistance, eliminating the need to apply the oil coating that serves as a barrier to oxidation for acid-pickled carbon steel.

Alternative methods include also mechanical cleaning such as abrasive blasting, grinding, wire brushing and hydrocleaning. These methods generally do not provide as clean a surface as pickling does.

References

Category:Metalworking
Category:Steelmaking


Q:

How to conduct an Accent Sensitive search in MySql

I have a MySQL table with utf8 general ci collation. In the table, I can see two entries:
abad
abád
I am using a query that looks like this:
SELECT *  FROM `words` WHERE `word` = 'abád'

The query result gives both words:
abad
abád
Is there a way to indicate that I only want MySQL to find the accented word? I want the query to only return
abád
I have also tried this query:
SELECT *  FROM `words` WHERE BINARY `word` = 'abád'

It gives me no results. Thank you for the help.

A:

If your searches on that field are always going to be accent-sensitive, then declare the collation of the field as utf8_bin (that'll compare for equality the utf8-encoded bytes) or use a language specific collation that distinguish between the accented and un-accented characters.
col_name varchar(10) collate utf8_bin

If searches are normally accent-insensitive, but you want to make an exception for this search, try;
WHERE col_name = 'abád' collate utf8_bin

A:

In my version (MySql 5.0), there is not available any utf8 charset collate for case insensitive, accent sensitive searches. The only accent sensitive collate for utf8 is utf8_bin. However it is also case sensitive.
My work around has been to use something like this:
SELECT * FROM `words` WHERE LOWER(column) = LOWER('aBád') COLLATE utf8_bin

A:

The MySQL bug, for future reference, is http://bugs.mysql.com/bug.php?id=19567.


<Canvas>
    <Kind>42</Kind>
    <Name>LightSettings</Name>
    <IsMinified>0</IsMinified>
    <XPosition>1543.000000000</XPosition>
    <YPosition>1.000000000</YPosition>
</Canvas>
<Widget>
    <Kind>2</Kind>
    <Name>ENABLE</Name>
    <Value>0</Value>
</Widget>
<Widget>
    <Kind>2</Kind>
    <Name>SMOOTH</Name>
    <Value>1</Value>
</Widget>
<Widget>
    <Kind>25</Kind>
    <Name>H</Name>
    <Value>1.000000000</Value>
</Widget>
<Widget>
    <Kind>25</Kind>
    <Name>S</Name>
    <Value>0.000000000</Value>
</Widget>
<Widget>
    <Kind>25</Kind>
    <Name>V</Name>
    <Value>0.500000000</Value>
</Widget>


Description:Scientists from UC Berkeley have captured images of a single atom rearranging its bonds, which is a first for the field. Until now, we’ve only been able to guess what the process looks like.(1:12)


Genetic variation observed at three tetrameric short tandem repeat loci HumTHO1, TPOX, and CSF1PO--in five ethnic population groups of northeastern India.
This paper portrays the genetic variation observed at three tetrameric short tandem repeat (STR) loci HumTHO1, TPOX, and CSF1PO in five ethnic population groups from northeastern India. The study also specifies the suitability of use of these markers for forensic testing. The populations studied included three tribal groups (Kuki, Naga and Hmar), one Mongoloid caste group (Meitei), and a religious caste group (Manipuri Muslims). The loci were highly polymorphic in the populations, and all loci met Hardy-Weinberg expectations. No evidence for association of alleles among the loci was detected. The probability of match for the three loci of the most frequent genotype in the five population groups ranged between 2.6 x 10(-4) and 6.6 x 10(-5). The average heterozygosity among the population groups was approximately 70% with the overall extent of gene differentiation among the five groups being high (Gst = 0.046). Genetic affinity among the populations reveal very close association between the Kuki, Hmar, Naga, and Meitei. The Manipuri Muslims, despite being found in the same region, have had no admixture with these populations and maintain a substantial distance with the other groups. The genetic polymorphism data suggest that the studied systems can be used for human identity testing to estimate the frequency of a multiple locus STR DNA profile in population groups of northeastern India.


Q:

HTML tag to simply give a text an id

Is there a html tag to simply give a text an id/class?
Let's say I have the text "email" in front of an input tag, and i want to change the text (with js) on button click. I'd need an id... p would kick the input on a new line (which i don't want) and font is a bit outdated.
Any ideas?

A:

The element for describing a subsequent input tag should be a label tag, which has to have a for attribute that contains the name of the corresponding input tag. You can therefore select that element as a label with a particular attribute.
Example
<label for="email">Email: </label><input type="text" name="email" />

and to select it and change its text:
jQuery('label[for=email]').text('your new label text');

Note that this is the only solution (for labeling inputs) which also meets accessibility standards.
You can style it any way you want using CSS.

A:

The <span> element is a generic (i.e. it has no associated semantics) inline element that can be used for marking some content for access via CSS / JS / etc.
However, "the text 'email' in front of an input" sounds very much like a <label> element so you should probably use that instead.


_location: /core-util-is

core-util-is

type: range

escapedName: core-util-is

description: The `util.is*` functions introduced in Node v0.12.

keywords: util isBuffer isArray isNumber isString isRegExp isThis isThat polyfill

license: MIT

type: git

test: tap test.js