When Addressing Trauma Makes a Difference: A Case Report of Undiagnosed Complex Post-traumatic Stress Disorder.

Complex post-traumatic stress disorder (C-PTSD) is an emergent diagnosis, which acknowledges the impact of prolonged interpersonal abuse on affect regulation, interpersonal functioning, and self-concept. We present the case of a 59-year-old woman who remained undiagnosed and untreated for this condition for three decades while under follow-up in mental health services for the diagnosis of personality disorder and bipolar disorder. The patient suffered repeated sexual abuse in her childhood, resulting in intrusive traumatic memories she emotionally and cognitively avoided, dissociative amnesia, a persistent inability to experience positive emotions, a persistent sense of guilt, re-experiencing phenomena, and hypervigilance toward others and their intentions to harm her. She persistently believed herself to be worthless, defective, inferior, and lacking value; had a history of affective dysregulation resulting in suspicion of bipolar disorder; and displayed a pattern of relationship avoidance. Addressing chronic trauma and assessing its impact offered deeper contextualization of the patient's symptoms and proved pivotal in redefining her diagnosis and providing access to trauma-focused psychotherapy, which is the mainstay of treatment for C-PTSD.

Partial Implant Rehabilitations in the Posterior Regions of the Jaws Supported by Short Dental Implants (7.0 mm): A 7-Year Clinical and 5-Year Radiographical Prospective Study.

Background: Short implants have been used in the restoration of edentulous jaws in the past several years. However, some studies have suggested that short implants are less successful than standard implants. The aim of this study is to investigate the outcome of short implants placed in the posterior maxilla or mandible following one-stage or immediate-function protocols with a follow-up of 7 years (clinically) and 5 years (radiographically). Methods: This study included 127 patients rehabilitated with 217 implants measuring 7 mm and supporting 157 fixed prostheses in the posterior segments of both jaws. Final abutments were delivered at the surgery stage and were loaded after 4 months in 116 patients (199 implants). The primary outcome measure was implant survival measured through life tables. Secondary outcome measures were marginal bone loss and the incidence of biological and mechanical complications at the patient level and implant level (evaluated through descriptive statistics). Results: Twenty-four patients (18.9%) with 45 implants (20.7%) were lost to the follow-up. In total, 32 implants failed (14.8%) in 22 patients (17.3%), resulting in a cumulative survival rate at 7 years of 81.2% for 7 mm implants in the rehabilitation of the posterior regions of the maxilla and mandible. The average (standard deviation) marginal bone loss was 1.47 mm (0.99 mm) at 5 years. The incidence rate of biological complications was 12.6% and 10.6% at the patient and implant levels, respectively. The incidence rate of mechanical complications was 21.3% for patients and 16.1% for implants. A higher failure rate was registered in smokers and in implant arrangements with a sequence of three fixtures in proximity. Conclusions: Within the limitations of this study, it can be concluded that the placement of 7 mm long implants for the partial implant-supported rehabilitation of atrophic posterior jaws is possible in the long term, judging by the survival rate and stable average marginal bone loss. Nevertheless, strict case selection should be performed, especially in smokers and with implant arrangements that provide a minimum of one unit in inter-implant distance.

Analysing vaccine efficacy evaluated in phase 3 clinical trials carried out during outbreaks.

In this paper we examine several definitions of vaccine efficacy (VE) that we found in the literature, for diseases that express themselves in outbreaks, that is, when the force of infection grows in time, reaches a maximum and then vanishes. The fact that the disease occurs in outbreaks results in several problems that we analyse. We propose a mathematical model that allows the calculation of VE for several scenarios. Vaccine trials usually needs a large number of volunteers that must be enrolled. Ideally, all volunteers should be enrolled in approximately the same time, but this is generally impossible for logistic reasons and they are enrolled in a fashion that can be replaced by a continuous density function (for example, a Gaussian function). The outbreak can also be replaced by a continuous density function, and the use of these density functions simplifies the calculations. Assuming, for example Gaussian functions, one of the problems one can immediately notice is that the peak of the two curves do not occur at the same time. The model allows us to conclude: First, the calculated vaccine efficacy decreases when the force of infection increases; Second, the calculated vaccine efficacy decreases when the gap between the peak in the force of infection and the peak in the enrollment rate increases; Third, different trial protocols can be simulated with this model; different vaccine efficacy definitions can be calculated and in our simulations, all result are approximately the same. The final, and perhaps most important conclusion of our model, is that vaccine efficacy calculated during outbreaks must be carefully examined and the best way we can suggest to overcome this problem is to stratify the enrolled volunteer's in a cohort-by-cohort basis and do the survival analysis for each cohort, or apply the Cox proportional hazards model for each cohort.

Soft-tissue, non-osteogenic distraction of the mandible and lower face in bilateral hemifacial microsomia-technical report.

The aim of this study is to present a sequential strategy of soft-tissue, non-osteogenic distraction with a novel device, followed by microvascular bony reconstruction for severe cases of mandibular hypoplasia. The case of a 21-year-old woman with Goldenhar syndrome is presented, whose mandible remained severely hypoplastic despite previous attempts at distraction and was not suitable for further osteogenic distraction. Soft tissue deficiency and pin track scarring prevented free fibular transfers. A personalized distractor, anchored to the cranium and the mandibular symphysis, was designed to expand the soft tissues while allowing for physiological temporomandibular joint (TMJ) movement without compression forces. Internal distractors were placed along the osteotomies to prevent condylar luxation. After completion of the soft tissue distraction, the native mandible was resected except for the condyles and reconstructed with two free fibula flaps. This report represents the proof of concept of a sequential approach to severe lower face soft-tissue and bone deficiency, which preserves TMJ function and avoids the transfer of poorly matched skin to the face.

Methadone Withdrawal-Related Psychosis in a Patient With Hormone-Dependent Breast Cancer: A Case Report.

Methadone withdrawal usually presents as a classical opiate withdrawal syndrome, including symptoms such as restlessness, pupillary dilation, sweating, insomnia, irritability, sneezing, nausea, vomiting, and diarrhea. It rarely manifests as psychosis. Here, we discuss the case of a 43-year-old female with a history of long-term methadone use who presented with first-episode psychosis during methadone down-titration. She exhibited persecutory delusions and auditory hallucinations, unrelated to classical opiate withdrawal symptoms. Medical tests were unremarkable. The patient was diagnosed with first-episode psychosis and was involuntarily admitted to our psychiatric hospital. As she suffered from hormone-dependent breast cancer and presented paliperidone-induced hyperprolactinemia, we switched this drug to aripiprazole, a prolactin-sparing antipsychotic. Her psychotic symptoms remitted in six weeks, with no reintroduction of methadone. It remains unclear whether this presentation is attributable to a rare manifestation of withdrawal or methadone's antipsychotic properties, masking an underlying psychotic disorder. This case contributes to understanding psychosis emergence post-opioid withdrawal, underscoring the need for further investigation into withdrawal-related psychosis and opioid antipsychotic properties. It also prompts the discussion of antipsychotic treatment in patients with comorbid breast cancer, while evidence about hyperprolactinemia as a risk factor for breast cancer remains conflicting.

Modelling the impact of contact tracing of symptomatic individuals on the COVID-19 epidemic

OBJECTIVES: With the declining numbers of coronavirus disease 2019 (COVID-19) cases in the state of São Paulo, Brazil, social distancing measures have gradually been lifted. However, the risk of a surge in the number of cases cannot be overlooked. Even with the adoption of nonpharmaceutical interventions, such as restrictions on mass gatherings, wearing of masks, and complete or partial closure of schools, other public health measures may help control the epidemic. We aimed to evaluate the impact of the contact tracing of symptomatic individuals on the COVID-19 epidemic regardless of the use of diagnostic testing. METHODS: We developed a mathematical model that includes isolation of symptomatic individuals and tracing of contacts to assess the effects of the contact tracing of symptomatic individuals on the COVID-19 epidemic in the state of São Paulo. RESULTS: For a selection efficacy (proportion of isolated contacts who are infected) of 80%, cases and deaths may be reduced by 80% after 60 days when 5000 symptomatic individuals are isolated per day, each of them together with 10 contacts. On the other hand, for a selection efficacy of 20%, the number of cases and deaths may be reduced by approximately 40% and 50%, respectively, compared with the scenario in which no contact-tracing strategy is implemented. CONCLUSION: Contact tracing of symptomatic individuals may potentially be an alternative strategy when the number of diagnostic tests available is not sufficient for massive testing.

Controvérsias em torno das identidades profissionais de licenciandos em biologia: um estudo inspirado na teoria ator-rede / Controversies around the professional identities of undergraduates in biology: a study inspired in actor-network theory

RESUMO: Este é um Estudo inspirado na Teoria Ator-Rede que buscou mapear a seguinte controvérsia envolvendo a identidade profissional de licenciandos em Ciências Biológicas: seriam as vivências formativas destes estudantes, de fato formativas, no sentido de construírem uma identidade com a profissão de professor? Em outras palavras, que disputas ocorrem em torno das identidades dos licenciandos no interior dos cenários formativos deles? Os dados foram coletados por meio de dois grupos focais com licenciandos formandos de uma grande universidade pública do sudeste brasileiro, a partir da metodologia da cartografia de controvérsias, referenciada pela Teoria Ator-Rede. Constatou-se que, ao longo da trajetória acadêmica dos licenciandos há composições de interesses (translações) que apresentam muito mais desvios que associações em relação à identidade docente, o que favorece a formação de uma extensa rede contraidentitária relativa à profissão de professor.

ABSTRACT: This is an study inspired in Actor-Network theory which sought to map the following controversy involving the professional identity of undergraduate on Biological Sciences: were the formative experiences of these students, in fact formative, in order to build an identity with teaching career? In other words, which disputes occur around the identities of these undergraduates within their formative scenarios? Data were collected through two focus groups with undergraduates from a large public university in southeastern Brazil, from the methodology of the mapping controversies, referenced by the Actor-Network Theory. It was found that, throughout the academic life of the undergraduates, there are interest compositions (translations) that presents much more deviations than associations in relation to teacher identity, which favors the formation of an extensive network against the teaching career.

Aprendendo a ser afetado: contribuições para a educação em ciências na educação infantil / Learning to be affected: contributions to science education in early childhood education

RESUMO: O vínculo entre educação científica e educação infantil tem se constituído de modo tímido. Isso porque, muitas vezes, pensa-se equivocadamente que a maneira como a criança pequena interroga e investiga o mundo à sua volta não é apropriada. No entanto, fazendo uso da teoria ator-rede e de sua concepção de aprendizagem, analisamos episódio no qual crianças de 4 e 5 anos estavam engajadas na exploração de pistas deixadas em um jardim de uma Unidade Municipal de Educação Infantil. Nossos achados indicam que as crianças participam ativamente de atividades investigativas e aprendem a ser afetadas pelos elementos constitutivos do espaço designado para a exploração. Além disso, as crianças foram capazes de transformar os objetos tecnológicos disponibilizados em instrumentos científicos. Nossa análise foi possível por romper com uma concepção de aprendizagem como apropriação conceitual. Nesse sentido, procuramos entender a aprendizagem como capacidade de ser afetado e, portanto, como construção de um corpo.

ABSTRACT: The link between Science Education and Early Childhood Education has been constituted in a timid way. This is because it is often thought that the way the young child investigates the world around him/her is wrong or not appropriate. However, using the actor-network theory and its conception of learning in this study, we analyze an episode in which children aged 4 and 5 years old were engaged in the exploration of clues left in the courtyard of a Municipal Unit of Early Childhood Education. Our findings indicate that children actively participate in investigative activities and learn to be affected by the constituent elements of the designated space for exploration. More over, children were able to turn technological objects available on scientific instruments. Through our analysis, we were able to break away from the concept of learning as conceptual appropriation. In that sense, we sought to understand learning as an ability to be affected and, therefore, as building a body.

Age and regional differences in clinical presentation and risk of hospitalization for dengue in Brazil, 2000-2014

OBJECTIVES: Dengue cases range from asymptomatic to severe, eventually leading to hospitalization and death. Timely and appropriate management is critical to reduce morbidity. Since 1980, dengue has spread throughout Brazil, affecting an increasing number of individuals. This paper describes age and regional differences in dengue’s clinical presentation and associated risk of hospitalization based on more than 5 million cases reported to the Brazilian Ministry of Health from 2000-2014. METHODS: We performed a retrospective analysis of ∼5,450,000 dengue cases, relating clinical manifestations and the risk of hospitalization to age, gender, previous infection by dengue, dengue virus serotype, years of formal education, delay to first attendance and the occurrence of dengue during outbreaks and in different Brazilian regions. RESULTS: Complicated forms of dengue occurred more frequently among those younger than 10 years (3.12% vs 1.92%) and those with dengue virus 2 infection (7.65% vs 2.42%), with a delay to first attendance >2 days (3.18% vs 0.82%) and with ≤4 years of formal education (2.02% vs 1.46%). The risk of hospitalization was higher among those aged 6-10 years old (OR 4.57; 95% CI 1.43-29.96) and those who were infected by dengue virus 2 (OR 6.36; 95% CI 2.52-16.06), who lived in the Northeast region (OR 1.38; 95% CI 1.11-2.10) and who delayed first attendance by >5 days (composite OR 3.15; 95% CI 1.33-8.9). CONCLUSIONS: In Brazil, the occurrence of severe dengue and related hospitalization is associated with being younger than 10 years old, being infected by dengue virus 2 or 3, living in the Northeast region (the poorest and the second most populated) and delaying first attendance for more than 2 days.

Overactive bladder - 18 years - Part II

ABSTRACT Traditionally, the treatment of overactive bladder syndrome has been based on the use of oral medications with the purpose of reestablishing the detrusor stability. The recent better understanding of the urothelial physiology fostered conceptual changes, and the oral anticholinergics – pillars of the overactive bladder pharmacotherapy – started to be not only recognized for their properties of inhibiting the detrusor contractile activity, but also their action on the bladder afference, and therefore, on the reduction of the symptoms that constitute the syndrome. Beta-adrenergic agonists, which were recently added to the list of drugs for the treatment of overactive bladder, still wait for a definitive positioning – as either a second-line therapy or an adjuvant to oral anticholinergics. Conservative treatment failure, whether due to unsatisfactory results or the presence of adverse side effects, define it as refractory overactive bladder. In this context, the intravesical injection of botulinum toxin type A emerged as an effective option for the existing gap between the primary measures and more complex procedures such as bladder augmentation. Sacral neuromodulation, described three decades ago, had its indication reinforced in this overactive bladder era. Likewise, the electric stimulation of the tibial nerve is now a minimally invasive alternative to treat those with refractory overactive bladder. The results of the systematic literature review on the oral pharmacological treatment and the treatment of refractory overactive bladder gave rise to this second part of the review article Overactive Bladder – 18 years, prepared during the 1st Latin-American Consultation on Overactive Bladder.

Overactive bladder - 18 years - Part I

ABSTRACT Abstract: Overactive bladder syndrome is one of the lower urinary tract dysfunctions with the highest number of scientific publications over the past two decades. This shows the growing interest in better understanding this syndrome, which gathers symptoms of urinary urgency and increased daytime and nighttime voiding frequency, with or without urinary incontinence and results in a negative impact on the quality of life of approximately one out of six individuals – including both genders and almost all age groups. The possibility of establishing the diagnosis just from clinical data made patients' access to specialized care easier. Physiotherapy resources have been incorporated into the urological daily practice. A number of more selective antimuscarinic drugs with consequent lower adverse event rates were released. Recently, a new class of oral drugs, beta-adrenergic agonists has become part of the armamentarium for Overactive Bladder. Botulinum toxin injections in the bladder and sacral neuromodulation are routine modalities of treatment for refractory cases. During the 1st Latin-American Consultation on Overactive Bladder, a comprehensive review of the literature related to the evolution of the concept, epidemiology, diagnosis, and management was conducted. This text corresponds to the first part of the review Overactive Bladder 18-years.

A public health risk assessment for yellow fever vaccination: a model exemplified by an outbreak in the state of São Paulo, Brazil

We propose a method to analyse the 2009 outbreak in the region of Botucatu in the state of São Paulo (SP), Brazil, when 28 yellow fever (YF) cases were confirmed, including 11 deaths. At the time of the outbreak, the Secretary of Health of the State of São Paulo vaccinated one million people, causing the death of five individuals, an unprecedented number of YF vaccine-induced fatalities. We apply a mathematical model described previously to optimise the proportion of people who should be vaccinated to minimise the total number of deaths. The model was used to calculate the optimum proportion that should be vaccinated in the remaining, vaccine-free regions of SP, considering the risk of vaccine-induced fatalities and the risk of YF outbreaks in these regions.

Risk of symptomatic dengue for foreign visitors to the 2014 FIFA World Cup in Brazil

Brazil will host the FIFA World Cup™, the biggest single-event competition in the world, from June 12-July 13 2014 in 12 cities. This event will draw an estimated 600,000 international visitors. Brazil is endemic for dengue. Hence, attendees of the 2014 event are theoretically at risk for dengue. We calculated the risk of dengue acquisition to non-immune international travellers to Brazil, depending on the football match schedules, considering locations and dates of such matches for June and July 2014. We estimated the average per-capita risk and expected number of dengue cases for each host-city and each game schedule chosen based on reported dengue cases to the Brazilian Ministry of Health for the period between 2010-2013. On the average, the expected number of cases among the 600,000 foreigner tourists during the World Cup is 33, varying from 3-59. Such risk estimates will not only benefit individual travellers for adequate pre-travel preparations, but also provide valuable information for public health professionals and policy makers worldwide. Furthermore, estimates of dengue cases in international travellers during the World Cup can help to anticipate the theoretical risk for exportation of dengue into currently non-infected areas.

Vectorial capacity, basic reproduction number, force of infection and all that: formal notation to complete and adjust their classical concepts and equations

A dimensional analysis of the classical equations related to the dynamics of vector-borne infections is presented. It is provided a formal notation to complete the expressions for the Ross' Threshold Theorem, the Macdonald's basic reproduction "rate" and sporozoite "rate", Garret-Jones' vectorial capacity and Dietz-Molineaux-Thomas' force of infection. The analysis was intended to provide a formal notation that complete the classical equations proposed by these authors.

The risk of acquiring the new influenza A(H1N1) for Brazilian travelers to Chile, Argentina and the USA

We estimate the risk of acquiring the new influenza A(H1N1) for Brazilian travelers to Chile, Argentina and the USA. This is done by a mathematical model that quantifies the intensity of transmission of the new virus in those countries and the probability that one individual has of acquiring the influenza depending on the date of arrival and time spent in the area. The maximum estimated risk reached 7.5 cases per 10,000 visitors to Chile, 17 cases per 10,000 travelers to Argentina and 23 cases per 10,000 travelers to the USA. The estimated number of imported cases until 27 July is 57 ± 9 from Chile, 136 ± 27 from the USA and 301 ± 21 from Argentina, which are in accord with the official figures. Estimating the number of imported cases was particularly important for the moment of the disease introduction into this country, but it will certainly be important again as a tool to calculate the number of future imported cases from northern countries in our next inter-epidemic season, were imported cases can constitute again the majority of the new influenza burden to the Brazilian health services.

Dynamics of the 2006/2007 dengue outbreak in Brazil

We analyzed dengue incidence in the period between October 2006-July 2007 of 146 cities around the country were Larval Index Rapid Assay (LIRA) surveillance was carried out in October 2006. Of these, we chosen 61 cities that had 500 or more cases reported during this period. We calculated the incidence coefficient, the force of infection (¼) and the basic reproduction number (R0) of dengue in those 61 cities and correlated those variables with the LIRA. We concluded that ¼ and R0 are more associated with the number of cases than LIRA. In addition, the average R0 for the 2006/2007 dengue season was almost as high as that calculated for the 2001/2002 season, the worst in Brazilian history.

Segurança e eficácia da sildenafila em pacientes com disfunção erétil secundária à lesão espinhal / Safety and efficacy of sildenafil in Brazilian men with erectile dysfunction secondary to spinal cord injury

Objetivo: Avaliar o efeito do sildenafil em pacientes brasileiros com disfunção erétil secundária à lesão de medula espinhal. Métodos: Os participantes foram examinados por ocasião da adesão ao estudo, e duas e seis semanas depois. Dados iniciaise de seguimento sobre a função sexual foram obtidos. Depois da segunda semana, a dose inicial de sildenafil (50 mg) podia ser ajustada, de acordo com a eficácia e tolerabilidade. A eficácia foi avaliada principalmente pelos escores nas questões 3 e 4 do questionário do Índice Internacional para Disfunção Erétil. Análises secundárias incluíram questões e domínios do índice, a avaliação da eficácia global, percentual de sucesso na relação sexual, respostas ao questionário de Qualidade de Vida e Função Erétil, além da satisfação da parceira. Resultados: Noventa e um pacientes foram avaliados quanto à eficácia e 94 quanto à segurança. A mediana da idade dos pacientes foi de 33 anos e a mediana do tempo entre a lesão medular e a adesão ao estudo de três anos. O sildenafil levou a um aumento significativo nos escores médios nas questões 3 e 4(p < 0,001 nas duas comparações), bem como em outras questõese em todos os domínios do Índice Internacional para Disfunção Erétil. A melhora na ereção foi relatada por 89% dos pacientes e a proporção de relações sexuais bem sucedidas aumentou de 6 para 74%(p < 0,001). Os escores médios do questionário de Qualidade de Vida e Função Erétil aumentaram de 60 para 74% (p < 0,001). Noventa por cento de 42 mulheres estavam moderadamente ou bastante satisfeitas com o tratamento do parceiro. Os efeitos adversos maiscomuns foram cefaléia (16%), rubor (11%) e congestão nasal (10%). Conclusões: Sildenafil se mostrou seguro e efetivo no tratamentode homens brasileiros portadores de disfunção erétil secundária à lesão traumática da medula espinhal.

Dengue and the risk of urban yellow fever reintroduction in Säo Paulo State, Brazil

OBJETIVO: Propor um modelo matemático para a estimativa da reprodutibilidade basal, R0, para a febre amarela urbana em uma área infestada pela dengue. MÉTODOS: O método utilizado considera que, como ambas as doenças säo transmitidas pelo mesmo vetor (Aedes aegypti), poder-se-ia aplicar todos os parâmetros quantitativos relativos ao mosquito, estimados pela fase inicial da curva de crescimento de casos de dengue, à dinâmica da febre amarela. Demonstra-se que o R0 da febre amarela é em média 43por cento menor que o da dengue. Esta diferença deve-se à viremia mais prolongada da dengue, bem como ao menor período de incubaçäo extrínseco daquele vírus no mosquito. RESULTADOS: Apresenta-se a aplicaçäo desta análise matemática à situaçäo epidemiológica da dengue no estado de Säo Paulo, para o ano de 2001, onde o número de casos de dengue aumentou de 3.582, em 2000 para 51.348, em 2001. Calculou-se o valor de R0 para a febre amarela para cada cidade do estado que tinha R0 para dengue maior que um. Estimou-se o número total de pessoas desprotegidas, sem vacina, e que vivem em áreas de alto risco para a febre amarela urbana. CONCLUSOES: Foi demonstrado que existe, um grande contingente de pessoas näo vacinadas contra febre amarela vivendo em áreas infestadas por Aedes aegypti no Estado de Säo Paulo, até aquela data (2001)

Direito ambiental: o meio ambiente e os desafios da contemporaneidade / Environmental law: the environment and social challenges of contemporary

São tratadas questões jurídicas ligadas à gestão e proteção das águas, aos diferentes aspectos da responsabilidade (civil, penal e administrativa) por degradação ambiental, ao ambiente do trabalho, ao princípio da precaução, ao uso de instrumentos financeiros na defesa ambiental (créditos, seguros), ao comércio internacional, às áreas protegidas e unidades de conservação, ao direito à informação socioambiental, à mineração, à participação nos processos administrativos ambientais, à gestão de resíduos sólidos, ao uso da ação civil pública (inclusive o TAC) e ao papel da Justiça e à hermenêutica constitucional na solução dos conflitos na seara ambiental.