Estudo longitudinal de famílias / Longitudinal study of families / Estudio longitudinal de familias

Introdução: O desenvolvimento da família é influenciado por diversos fatores de sua organização interna e de ordem ambiental, social, cultural, econômica e política. Em contexto de pobreza os riscos são maiores. Fatores de proteção, como boa organização familiar e rede social de apoio podem diminuir as consequências negativas da pobreza. São escassas as pesquisas longitudinais sobre vulnerabilidade e resiliência nas famílias. Objetivo: Este artigo descreve o desenvolvimento de três famílias ao longo de 15 anos, estudadas por meio de entrevistas em casa, parte de uma coorte populacional de um bairro de Porto Alegre (RS). Buscaram-se associações entre a qualidade das relações nessas famílias e sua saúde física e mental, especialmente a do filho, foco da pesquisa. Métodos: Selecionaram-se no arquivo da pesquisa as três primeiras famílias (do total de 148) das quais se tinham os resultados completos das cinco visitas realizadas aos quatro meses e aos dois, quatro, nove e 15 anos de um filho. Realizou-se análise qualitativa dos registros em busca de categorias para compreender a vida e as relações interpessoais nas famílias. O estudo foi realizado em conjunto por duas pesquisadoras, médicas especialistas em desenvolvimento humano. As categorias identificadas na análise e estudadas nas cinco etapas foram: configuração familiar, situação socioeconômica, situações traumáticas, saúde física, saúde relacional e mental, evolução cognitiva e escolar do filho. Resultados: As três famílias, todas de classe C, com filhos sem problemas de saúde física, tiveram evolução suficientemente boa, apesar de todas enfrentarem múltiplos problemas, inclusive separações e mortes precoces. A relação com o sistema de saúde e escola era boa e similar para as três. A jovem com menos problemas de saúde mental foi aquela que sofreu perdas mais importantes: morte dos pais. Tinha uma estrutura familiar multigeracional sólida desde a primeira infância, com relações interpessoais predominantemente colaborativas e amorosas. Conclusões: O artigo busca avançar na compreensão da resiliência nas famílias em situações de vulnerabilidade. Concluímos que essas três famílias, uma delas mais que as outras, foram suficientemente saudáveis na tarefa de educar seus filhos sem desenvolverem problemas mentais graves. Propomos que o bom desenvolvimento se associa com a adequação e amorosidade dos cuidados com a etapa do ciclo vital, mesmo enfrentando situações problemáticas. Essas qualidades precisam estar associadas à estabilidade socioeconômica básica e a bons serviços de saúde e escola.

Introduction: Family development is influenced by it's internal organization and environmental factors, socioeconomic, cultural and political. In poor contexts there are more risks to development. Protection factors like good family organization and social network may decrease the risks. Longitudinal research about vulnerability and resilience in families is scarse. Objective: This article describes the development of three families over 15 years through interviews at home. The families were part of a populational cohort of a neighborhood in Porto Alegre (RS). We looked for links between the quality of relationships and the physical and mental health of these families, especially of the child focus of the research. Methods: We selected in the research archives the first three families (of a total of 148) for which we had full results of the five interviews at four months and two, four, nine and fifteen years of a child. We did a qualitative analysis of the records looking for parameters to understand the life and interpersonal relationships of these families. This study was done by two researchers, both experts in Human Development. The categories identified in the analysis of the five phases were: family structure, socioeconomic situation, traumatic experiences, physical, mental and relational health and cognitive evolution of the child. Results: All three families belonged to economical class C. The children were in good physical health and had sufficiently good general development, having faced multiple problems, including parental separation and early parental death. The relationship with the health and school systems was good in all of them. The youth with less mental health problems was the one who suffered the heaviest loss: early death of both parents. Her family had strong multigenerational ties since her early days, with predominant collaborative and loving relationships. Conclusions: This article aims to contribute to the comprehension of resilience in families in the context of vulnerability. We can say that these three families were healthy enough in the task of bringing up children without any serious mental health problem. We suggest that healthy development is associated with loving interfamily relationships adequate to each phase of development, notwithstanding dramatic events. This needs to be supported by basic economic stability and adequate school and health systems.

Introducción: El desarrollo de la familia es influenciado por su organización interna y factores ambientales, sociales, culturales, económicos y políticos. En contextos pobres los riesgos son mayores. Factores de protección como buena organización familiar y red social de apoyo pueden disminuir las consecuencias negativas de la pobreza. Son pocas las investigaciones longitudinales de vulnerabilidad y resiliencia de las familias. Objetivo: Este artículo describe el estudio del desarrollo de tres familias a lo largo de 15 años, a través de entrevistas en domicilio, parte de una cohorte poblacional de un barrio de Porto Alegre (RS). Se buscaron correlaciones entre la calidad de las relaciones de esas familias y su salud física y mental, especialmente la del hijo foco de la investigación. Métodos: Fueron seleccionadas en el archivo de la investigación las tres primeras familias (de un total de 148) de las cuales se tenían los resultados completos de las cinco visitas realizadas, a los 4 meses, y a los 2, 4, 9, y 15 años de un hijo. Fue realizado un análisis cualitativo de los registros en busca de categorías para comprender la vida y las relaciones interpersonales en las familias. El estudio fue hecho en conjunto por dos investigadoras, médicas especialistas en desarrollo humano. Las categorías identificadas en el análisis y estudiadas en las cinco etapas fueron: configuración familiar, situación socioeconómica, situaciones traumáticas, salud física, salud relacional y mental, evolución cognitiva y escolar del hijo. Resultados: Las tres familias, todas de clase C, con hijos sin problemas de salud física, tuvieron evolución suficientemente buena, a pesar de que todas enfrentaron múltiples problemas, incluso separaciones y muertes precoces. La relación con el sistema de salud y escuela era buena y similar para las tres. La joven con menos problemas de salud mental fue aquella que sufrió las mayores pérdidas: muerte de los padres. Tenía una estructura familiar multigeneracional sólida desde la primera infancia, con relaciones interpersonales predominantemente colaborativas y amorosas. Conclusiones: El artículo pretende avanzar en la comprensión de la resiliencia en las familias en situaciones de vulnerabilidad. Concluimos que esas tres familias, una de ellas más que las otras, fueron suficientemente saludables en la tarea de educar a sus hijos sin que desarrollaran problemas mentales graves. Proponemos que el buen desarrollo se asocia con el amor y adecuación de los cuidados a la etapa del ciclo vital, aun enfrentando situaciones problemáticas. Esas calidades necesitan estar asociadas a la estabilidad socioeconómica básica y buenos servicios de salud y escuela.

Substance use and adolescent mental health during the COVID-19 pandemic in Brazil: a longitudinal approach

Abstract Objective: To describe the changes in alcohol and drug use by Brazilian adolescents during the COVID-19 pandemic (April-August 2021), and to analyze the relationship between alcohol use changes and psychiatric symptomatology. Methods: A secondary analysis with a longitudinal approach was performed with data from a cluster-randomized controlled trial, conductedin73publicmiddleschoolsinthreeBrazilian cities, to evaluate the effectiveness of a drug use prevention program. The sample included 535 students (61% girls; Mage = 15.2 years). Data were collected pre-intervention (February-March 2019), after 9 months (November-December 2019), and after 26 months (April-August 2021), when the students were in their first year of high school. The authors analyzed drug use prevalence (alcohol, binge drinking, tobacco, inhalants, marijuana, cocaine, and crack) in a lifetime, past year, and past month periods, and the association between alcohol use change subsamples with psychiatric symptoms. Logistic regressions were adjusted by sex, age, socioeconomic status, city, and group (control and intervention). Results: The present findings suggest that the COVID-19 pandemic led to a decrease in past-year substance use and in past-month substance use frequency, despite the gradually increased (but decelerating) prevalence of lifetime use. However, some adolescents initiated, maintained, or increased the frequency of their alcohol use. Mainly, they were more likely to present behavioral problems, as well as symptoms of inattentive hyperactivity, and peer and emotional problems. Conclusions: Despite the extensive decline in substance use during the pandemic period, these results suggest an association between previous mental health conditions and behavioral risk factors, leading to increased alcohol consumption and behavioral disorders manifestations.

Novo Modelo Incremental para Predição de Mortalidade na Hipertensão Pulmonar Pré-Capilar / New Incremental Model for Predicting Mortality in Pre-Capillary Pulmonary Hypertension

Resumo Fundamento: Na hipertensão pulmonar (HP), é necessária a identificação de marcadores prognósticos de fácil obtenção associados com disfunção do ventrículo direito (VD) e sobrevida. Objetivo: Avaliar a associação do índice de anisocitose eritrocitária (RDW, do inglês red cell distribution width) com parâmetros ecocardiográficos e sobrevida em pacientes com HP pré-capilar, com o desenvolvimento de um modelo de predição de mortalidade. Métodos: Estudo observacional, longitudinal, prospectivo, conduzido entre maio de 2019 e dezembro de 2022. Trinta e quatro pacientes com HP pré-capilar submeteram-se à realização de ecocardiograma bidimensional e hemograma. Um ponto de corte de 14,5% foi adotado para definir o RDW como alterado (≥14,5%) ou normal (<14,5%). Valores de p<0,05 foram considerados significativos. Resultados: O RDW médio foi 14,4%. Houve uma diferença significativa na saturação periférica de oxigênio (SpO2) (p=0,028), strain do VD (p=0,047) e derrame pericárdico (p=0,002) entre os grupos com RDW normal e elevado. Durante um período mediano de 15 meses, 20,6% dos pacientes foram a óbito. Os pacientes com RDW aumentado tiveram uma sobrevida global mais curta (44,7%, log-rank p=0,019), sendo um preditor de mortalidade na regressão univariada de Cox. A adição do strain do VD < 16% e da SpO2 ≤93% ao modelo incluindo somente RDW mostrou valor incremental na predição de mortalidade (χ2=8,2, p=0,049; χ2=12,4, p=0,041), com área sob a curva ROC (do inglês, Receiver Operating Characteristic) aumentada (0,729 vs. 0,837 vs. 0,909) e probabilidade de sobrevida diminuída (44.7% vs. 35.6% vs. 25%, log-rank p=0,019). Conclusões: O RDW fornece informações sobre a gravidade da HP pré-capilar pela sua correlação com parâmetros ecocardiográficos de disfunção do VD e mortalidade, a qual é melhor predita por um modelo incluindo RDW, strain do VD e SpO2.

Abstract Background: In pulmonary hypertension (PH), the identification of easily obtainable prognostic markers associated with right ventricular (RV) dysfunction and survival is needed. Objective: To evaluate the association of red cell distribution width (RDW) with clinical, echocardiographic parameters and survival in patients with pre-capillary PH, with the development of a mortality prediction model. Methods: Observational, longitudinal, and prospective study conducted from May 2019 to December 2022. Thirty-four patients with pre-capillary PH underwent two-dimensional echocardiography and complete blood count. A cutoff point of 14.5% was considered to define RDW as altered (≥14.5%) or normal (<14.5%). P values <0.05 were considered significant. Results: The median RDW was 14.4%. There was a significant difference in peripheral arterial oxygen saturation (SpO2) (p=0.028), RV strain (p=0.047), and pericardial effusion (p=0.002) between the normal and elevated RDW groups. During a median follow-up of 15 months, 20.6% died. Patients with increased RDW had a shorter overall survival (44.7%, log-rank p=0.019), which was a predictor of mortality in univariate Cox regression (HR 8.55, p=0.048). The addition of RV strain <16% and SpO2 ≤93% to the model including RDW alone showed incremental value in predicting mortality (χ2=8.2, p=0.049; χ2=12.4, p=0.041), with increased area under the receiver operating characteristic curve (0.729 vs. 0.837 vs. 0.909) and decreased probability of survival (44.7% vs. 35.6% vs. 25%, log-rank p=0.019). Conclusions: RDW provides information on the severity of pre-capillary PH by correlating with echocardiographic parameters of RV dysfunction and mortality, which is best predicted by a model including RDW, RV strain and SpO2.

Variação da velocidade de marcha e fatores clínicos associados em pessoas idosas da atenção primária à saúde: estudo longitudinal / Variation in gait speed and associated clinical factors in elderly people in primary health care: longitudinal study

Resumo: analisar a variação da velocidade da marcha e os fatores clínicos associados em pessoas idosas da Atenção Primária à Saúde, no período mínimo de dois anos. Materiais e método: estudo longitudinal prospectivo, do tipo quantitativo, subprojeto do projeto de pesquisa matriz intitulado "As variações da fragilidade física e da funcionalidade de idosos da atenção primária à saúde", desenvolvido com 389 idosos da atenção primária à saúde. As coletas de dados foram realizadas nos anos de 2019 (1ª onda) e 2022 (2ª onda), com idosos assistidos em uma Unidade Básica de Saúde de Curitiba-PR. Aplicou-se questionário com variáveis sociodemográficas e clínicas, incluindo autorrelato de agravos em saúde e história pregressa; teste Timed Up and Go para verificar o risco de queda; e avaliação do fenótipo da fragilidade física, com destaque para a velocidade da marcha. Os dados foram analisados de forma descritiva, a partir da distribuição de frequência absoluta e relativa, média e desvio padrão; bem como análise inferencial por meio de testes não paramétricos qui-quadrado, Wilcoxon Signed Rank e Exato de McNemar, para amostras pareadas, a fim de comparação entre os dois momentos (1ª e 2ª avaliação); e regressão logística para propor modelo preditivo, o qual considerou a entrada de variáveis que apresentaram p-valor =0,20 (técnica enter hierárquico), permanecendo no modelo as variáveis que apresentaram valor de p=0,05 ou que ajustassem o modelo. Considerou-se o nível de significância de 5%. O estudo recebeu parecer favorável do Comitê de Ética em Pesquisa. Resultados: a prevalência de VM reduzida na 1ª onda (n=389) foi de 20,8% (n=81). Com relação à 2ª onda (n= 128), 21 (16,4%) participantes apresentaram VM reduzida, dos quais 13 (61,9%) já dispunham dessa condição na baseline e 8 (6,25%) da amostra apresentaram redução da VM durante o seguimento (incidência). Ainda, 8 (7,5%) idosos com VM reduzida na 1ª onda apresentaram melhora desse parâmetro , indicando VM preservada na 2ª onda. Observou-se acréscimo na média de velocidade de marcha dos idosos de 0,04m/s durante o seguimento (de 1,03 m/s para 1,07m/s), no entanto, a variação não foi estatisticamente significativa (p=1,00). Os fatores clínicos, embora associados à VM reduzida na 1ª onda de avaliação, não apresentaram relação estatisticamente significativa à mudança na VM dos idosos durante o seguimento do estudo. O modelo preditivo de VM reduzida indicou que as variáveis comprometimento cognitivo sugestivo (OR:19,62; IC95%=1,93-209,92; p=0,014), força de preensão manual (OR:1,97; IC95%=1,04-3,71; p=0,036) risco de queda (OR:4,07; IC95%=2,27-7,28; p<0,001), histórico de quedas no último ano (OR:1,81; IC95%=0,99-3,26; p=0,050), problemas metabólicos (OR:1,97; IC95%=1,09-3,55; p=0,024), auditivo (OR:0,33; IC95%=0,14-0,80; p=0,013) e cardiovascular (OR:2,08; IC95%=1,02-4,26; p=0,044), aumentaram as chances de as pessoas idosas apresentarem VM reduzida. Conclusão: não houve variação significativa da VM no período investigado e os fatores clínicos se mostraram associados à VM reduzida apenas na 1ª onda de avaliação. É importante que a equipe de saúde da atenção primária desenvolva ações de acompanhamento, bem como de rastreio da velocidade da marcha e das condições clínicas relacionadas à saúde, com vistas a evitar a progressão da síndrome da fragilidade das pessoas idosas.

Abstract: to analyze the variation in gait speed and associated clinical factors in elderly people in Primary Health Care, over a minimum period of two years. Materials and method: prospective longitudinal study, quantitative, subproject of the main research project entitled "Variations in physical frailty and functionality of elderly people in primary health care", developed with 389 elderly people in primary health care. Data collection was carried out in 2019 (1st wave) and 2022 (2nd wave), with elderly people cared for in a Basic Health Unit in Curitiba-PR. A questionnaire was applied with sociodemographic and clinical variables, including self-report of health problems and past history; Timed Up and Go test to check the risk of falling; and assessment of the physical frailty phenotype, with emphasis on gait speed. The data were analyzed descriptively, based on absolute and relative frequency distribution, mean and standard deviation; as well as inferential analysis using non-parametric chi-square tests, Wilcoxon Signed Rank and McNemar's exact tests, for paired samples, in order to compare the two moments (1st and 2nd assessment); and logistic regression to propose a predictive model, which considered the entry of variables that presented a p-value =0.20 (hierarchical enter technique), with variables that presented a p-value =0.05 or that adjusted the model remaining in the model. A significance level of 5% was considered. The study received a favorable opinion from the Research Ethics Committee. Results: the prevalence of reduced MV in the 1st wave (n=389) was 20.8% (n=81). In relation to the 2nd wave (n= 128), 21 (16.4%) participants presented reduced MV, of which 13 (61.9%) already had this condition at baseline and 8 (6.25%) of the sample presented a reduction of MV during follow-up (incidence). Furthermore, 8 (7.5%) elderly people with reduced MV in the 1st wave showed improvement in this parameter, indicating preserved MV in the 2nd wave. An increase in the elderly's average walking speed of 0.04 m/s was observed during the follow-up (from 1.03 m/s to 1.07 m/s), however, the variation was not statistically significant (p=1 ,00). Clinical factors, although associated with reduced MV in the 1st wave of evaluation, did not present a statistically significant relationship to the change in the elderly's MV during the study follow-up. The predictive model of reduced MV indicated that the variables suggestive cognitive impairment (OR:19.62; CI95%=1.93-209.92; p=0.014), handgrip strength (OR:1.97; CI95%= 1.04-3.71; p=0.036) risk of falling (OR:4.07; 95%CI=2.27-7.28; p<0.001), history of falls in the last year (OR:1.81; CI95%=0.99-3.26; p=0.050), metabolic problems (OR:1.97; CI95%=1.09-3.55; p=0.024), auditory (OR:0.33; CI95 %=0.14-0.80; p=0.013) and cardiovascular (OR:2.08; 95%CI=1.02-4.26; p=0.044), increased the chances of elderly people having reduced MV. Conclusion: there was no significant variation in MV during the period investigated and clinical factors were associated with reduced MV only in the 1st wave of evaluation. It is important that the primary care health team develops follow-up actions, as well as tracking the speed of MV. gait and healthrelated clinical conditions, with a view to preventing the progression of frailty syndrome in elderly people.

Longitudinal associations between organophosphate esters exposure and blood pressure among school aged children in Beijing / 中国学校卫生

Objective@#To explore the longitudinal association between organophosphate esters (OPEs) exposure and blood pressure in children, so as to provide a reference for identifying the effects of OPEs exposure on child health.@*Methods@#A total of 404 children from the Beijing Child Growth and Health Cohort (PROC) were enrolled using a case cohort study design, baseline physical examination, urine collection, questionnaires survey were administered in 2018 and follow up surveys in 2019-2020 and 2023. Participants were divided into case group ( n =140) and control group ( n =264) according to the observation of new onset of high blood pressure during the follow up period. High performance liquid chromatography tandem mass spectrometry was used to detect diethyl phosphate (DEP)，bis (2-chloroethyl) phosphate (BCEP)，bis (1-chloro-2-propyl) phosphate, (BCIPP), diphenyl phosphate(DPHP), dibutyl phosphate (DnBP), bis (1,3-dichloro-2-propyl) phosphate(BDCIPP), bis(2-butoxyethyl) phosphate(BBOEP), bis (2-butoxyethyl) 2-hydroxyethyl phosphate (BBOEHEP), 4-hydroxyphenyl diphenyl phosphate (4-OH-TPHP). Generalized linear mixed models and Quantile g computation models were developed to analyze the longitudinal associations between OPEs individual/mixed exposure and blood pressure in children.@*Results@#The detection range of 9 OPEs metabolites,including DEP, BCEP, BCIPP, DPHP, DnBP, BDCIPP, BBOEP, BBOEHEP and 4-OH-TPHP at three time points (baseline, first follow up and second follow up) were 27.7%-92.1%, 24.0%-99.3% and 39.2%-90.9% respectively. Without adjustment for covariates such as gender, age, body mass index, Tanner stage, parental education, and monthly household income, and family history of hypertension, the increase of BDCIPP concentration and mixed exposure of OPEs may reduce children s systolic blood pressure( β= -0.85，-2.40，95%CI=-1.69--0.01，-3.30--1.50，P <0.05). After adjusting for the covariates, the longitudinal association of individual OPEs or mixed exposure with pediatric BP was not statistically significant ( P >0.05).@*Conclusion@#Children are commonly exposed to OPEs, and although no significant longitudinal associations are observed between exposure to OPEs and blood pressure among school aged children in Beijing, it is recommended that child exposure should be minimized whenever possible.

Comparison of the predictive value of new simplified insulin resistance assessment indexes in identifying left ventricular subclinical dysfunction in T2DM patients / 解放军医学杂志

Objective To investigate the predictive value of new simplified insulin resistance(IR)assessment indexes in identifying subclinical left ventricular systolic function impairment in patients with type 2 diabetes mellitus(T2DM).Methods A total of 150 T2DM patients with preserved left ventricular ejection fraction(LVEF≥50%)who were admitted to Department of Endocrinology of the First Affiliated Hospital of Air Force Medical University from June 2021 to December 2021 were retrospectively analyzed.All patients underwent two-dimensional speckle tracking echocardiography to measure left ventricular global longitudinal strain(GLS).According to GLS value,the subjects were divided into the normal group(GLS≥18%group,n=80)and the impaired group(GLS<18%group,n=70).Some new simplified IR assessment indicators were calculated and compared between the two groups,including body mass index(BMI),TG/HDL-C ratio,triglyceride-glucose(TyG)index,TyG-BMI index,TyG-WHR and metabolic score for IR(METS-IR).Correlation between the GLS and the new simplified IR assessment indexes was analyzed.The receiver operating characteristic(ROC)curve was used to analyze the diagnostic efficacy of different simplified IR assessment indexes,with the area under the curve(AUC)calculated.Furthermore,according to whether the subjects were complicated with hypertension,binary logistics regression analysis was performed to explore the independent correlation between the simplified IR assessment index and GLS<18%.Results Total 150 were included with aged(54.5±13.7)years with 96(64.0%)men and 54(36.0%)women.Compared with the GLS≥18%group,the TG/HDL-C ratio,TyG index,TyG-BMI,and METS-IR of subjects in the GLS<18%group were significantly increased(P<0.05).Pearson correlation analysis showed that TG/HDL-C ratio,TyG index,TyG-BMI,TyG-WHR,and METS-IR were negatively correlated with GLS(P<0.05).ROC analysis showed that TyG index had a certain predictive value for the evaluation of GLS<18%(AUC=0.678,95%CI 0.591-0.765,P<0.001).Stratification based on hypertension and further adjusting for confounding factors,TyG index remains significantly associated with GLS<18%(OR=3.249,95%CI 1.045-10.103,P=0.042).Conclusions The novel simplified insulin resistance evaluation indexes are closely associated with left ventricular subclinical systolic dysfunction in T2DM patients with preserved ejection fraction.TyG index is an effective index to identify left ventricular subclinical dysfunction in these populations.

Correlation between sleep disorder and postoperative quality of life in patients with liver cancer:a longitudinal study / 现代临床护理

Objective To investigate the sleep disorders and its effects on the changes in quality of life in patients with liver cancer from the hospital admission to 6 months after surgery and to analyse the correlation between the sleep disorder and quality of life.Methods A total of 214 patients who underwent surgery for liver cancer for the first time were included in the study.Demographic questionnaire,Pittsburgh sleep quality index(PSQI),and functional assessment of cancer therapy-hepatobiliary(FACT-Hep)were used for the investigation at admission and at 1,3 and 6 months after surgery.Multiple linear regression was employed to analyse the correlation between the sleep disorders at the admission and its effect on quality of life up to 6 months after surgery.Results Toally 214 patients finished the study at admission and 209 finished the study 1 month after surgery,and 208 finished the stuoly 3 months after surgery,and 205 patients finished the study 6 months after surgery.The scores of both of PSQI at admission and the quality of life at 6 months after surgery varied across the tested time points with a statistically significant difference(both P<0.001).The overall level of sleep disorder in the patients showed a characteristic pattern with initially increasing and then decreasing,and the quality of life presented a characteristic tendency of starting from high to low and then gradually increasing.It showed that the sleep disorder at admission was attributive to the poorer quality of life at 6 months after surgery.The hierarchical regression analysis showed that among the patients at BCLC Stage A,sleep disorder at admission was the influencing factor of the quality of life at 6 months after surgery.Conclusions The sleep disorder and quality of life in the patients who had surgical operations for hepatocellular carcinoma both changed dynamically from admission to the 6 months after surgery.The quality of life was poor in the patients with sleep disorder at admission.Therefore,medical staff should enhance the sleep management at admission,conduct dynamic assessment of the sleep disorder and quality of life of the patients,and then develop continuity nursing measures to improve the quality of life after surgery.

Longitudinal extrauterine growth restriction in extremely preterm infants: current status and prediction model / 中国新生儿科杂志

Objective:To study the current status of longitudinal extrauterine growth restriction (EUGR) in extremely preterm infants (EPIs) and to develop a prediction model based on clinical data from multiple NICUs.Methods:From January 2017 to December 2018, EPIs admitted to 32 NICUs in North China were retrospectively studied. Their general conditions, nutritional support, complications during hospitalization and weight changes were reviewed. Weight loss between birth and discharge > 1SD was defined as longitudinal EUGR. The EPIs were assigned into longitudinal EUGR group and non-EUGR group and their nutritional support and weight changes were compared. The EPIs were randomly assigned into the training dataset and the validation dataset with a ratio of 7∶3. Univariate Cox regression analysis and multiple regression analysis were used in the training dataset to select the independent predictive factors. The best-fitting Nomogram model predicting longitudinal EUGR was established based on Akaike Information Criterion. The model was evaluated for discrimination efficacy, calibration and clinical decision curve analysis.Results:A total of 436 EPIs were included in this study, with a mean gestational age of (26.9±0.9) weeks and a birth weight of (989±171) g. The incidence of longitudinal EUGR was 82.3%(359/436). Seven variables (birth weight Z-score, weight loss, weight growth velocity, the proportion of breast milk ≥75% within 3 d before discharge, invasive mechanical ventilation ≥7 d, maternal antenatal corticosteroids use and bronchopulmonary dysplasia) were selected to establish the prediction model. The area under the receiver operating characteristic curve of the training dataset and the validation dataset were 0.870 (95% CI 0.820-0.920) and 0.879 (95% CI 0.815-0.942), suggesting good discrimination efficacy. The calibration curve indicated a good fit of the model ( P>0.05). The decision curve analysis showed positive net benefits at all thresholds. Conclusions:Currently, EPIs have a high incidence of longitudinal EUGR. The prediction model is helpful for early identification and intervention for EPIs with higher risks of longitudinal EUGR. It is necessary to expand the sample size and conduct prospective studies to optimize and validate the prediction model in the future.

Longitudinal mixed methods and its application progress in nursing / 中华护理杂志

This review introduces the concept,design and implementation of longitudinal mixed methods research.It summarizes its common applications,including the in-depth exploration of potential causes and association among variables of the complex phenomenon over time,the comprehensive evaluation of intervention effectiveness,the identification of facilitators and challenges for implementation,as well as the exploration of changes in behavior and underlying mechanisms.Moreover,this review analyzes existing challenges and future insights of this method.In conclusion,this review aimed to strengthen the nursing researchers'understanding of longitudinal mixed methods research and provide insights for future related studies.

Expression of autophagy-related genes Beclin1 and LC3 in ossified tissues of posterior longitudinal ligament of cervical spine and correlation analysis with osteogenic factors / 中国脊柱脊髓杂志

Objectives:To investigate the expression levels of autophagy-related genes Beclin1 and LC3 in ossified tissues of posterior longitudinal ligament in cervical spine and their correlations with osteogenic factors.Methods:18 posterior longitudinal ligament tissue specimens from cervical ossification of posterior longitudinal ligament(OPLL)patients underwent OPLL surgical removal from October 2020 to May 2021(OPLL group)and 15 tissue specimens of the posterior longitudinal ligament of the cervical spine that were not ossified(non-OPLL group)were collected.The morphological changes of posterior longitudinal ligament tissues were observed by hematoxylin-eosin(HE)staining;the deposition of calcium salts was observed by Von Kossa staining;The mRNA and protein expression levels of Beclin1,microtubule associated protein light chain 3(LC3),and the osteogenic factors runt-related transcription factor 2(RUNX2),bone morphogenetic protein-2(BMP2),and Osterix in the specimens of the two groups were determined with immunohistochemical staining and RT-qPCR respectively;Pearson correlation analysis was used to explore the relationship between Beclin1,LC3,RUNX2,BMP2,and Osterix.Results:Compared with the non-OPLL group,the cell morphology in the OPLL group was larger and irregular in shape,and the nuclei were more obvious;Von Kossa staining showed that there was no obvious calcium salt deposition in the non-OPLL group,whereas brownish-black calcium salts could be seen in the OPLL group,which were aggregated into flakes or clusters;The expression levels of Beclin1,LC3,RUNX2,BMP2 and Osterix proteins and mRNA in the OPLL group were higher than those in the non-OPLL group(P＜0.05);Beclin1 mRNA expression level was significantly correlated with BMP2,RUNX2 and Osterix(P＜0.05,r＞0.5),while LC3 was not correlated with osteogenic factors.Conclusions:The autophagy-related genes Beclin1 and LC3 are significantly overexpressed in ossified tissues of posterior logitudinal ligament of cervical spine,and Beclin1 is closely related to posterior longitudinal ligament osteogenesis.

Simulation of Subgroup Analysis Methods with Longitudinal Data Containing Measurement Errors and Missingness / 中国卫生统计

Objective To develop a subgroup analysis method that can simultaneously deal with longitudinal data containing measurement errors and dropouts.Methods Subgroup analysis was carried out based on a threshold regression model.A new generalized unbiased estimation equation is constructed by using the independence between repeated measurements to deal with measurement errors and introducing an inverse probability weighting matrix to deal with missing response.Results The computer stochastic simulation shows that the proposed estimation method is effective in dealing with measurement errors and dropouts,and has smaller bias and mean square error than the generalized estimation equation method without correcting measurement errors or dropouts.Conclusion In subgroup analysis,when there are measurement errors in covariables and missing values in response variables,it is usually necessary to deal with the measurement errors and missing values in order to obtain reliable parameter estimation.

Application of Linear Mixed Model Tree in Longitudinal Trajectory of Body Mass Index / 中国卫生统计

Objective To understand the trajectory and classification of adult body mass index(BMI)in Jiangsu Province.Methods Based on China Health and Nutrition Survey,this study used the linear mixed model tree to explore the trajectory and classification of BMI of people aged 18-65 in Jiangsu Province.Results The linear mixed model tree had 13 nodes and the depth was 6.The classification nodes were baseline BMI,average calorie intake and baseline age.Conclusion The linear mixed model tree can identify the trajectory of BMI and expand the research method of longitudinal data.

Longitudinal relationships between solution-focused thinking and depressive symptoms in college students / 中国心理卫生杂志

Objective:To investigate the longitudinal relationship between solution-focused thinking and de-pressive symptoms in college students.Methods:A total of 261 college students were assessed with the Solution-Fo-cused Inventory(SFI)and Self-rating Depression Scale(SDS)in a 3-month interval.Data were analyzed with re-petitive measures analysis of variance and the cross-lagged panel model.Results:The detection rates for depressive symptoms at baseline and 3-month laterwere 39.46％and 47.89％,respectively.The scores of problem disengage-ment showed decrease after 3 months(P＜0.01).In the cross-lagged model,the baseline scores of SFI could signif-icantly predict the decrease in scores of SDS after 3 months(β=-0.19,P＜0.05),while the baseline scores of SDS could not predict the scores of SFI after 3 months(β=-0.05,P＞0.05).Conclusion:The findings suggest that solution-focused thinking may alleviate depressive symptoms.

Changes of quantitative CT indexes in chronic obstructive pulmonary disease patients and correlations with pulmonary function indicators / 中国医学影像技术

Objective To observe changes of CT quantitative indexes in patients with untreated chronic obstructive pulmonary disease(COPD)and relationships with pulmonary function indicators.Methods Totally 99 patients with untreated COPD were retrospectively enrolled.According to the degrees of airflow obstruction,the patients were divided into group A(GOLD grade 1 with mild obstruction,n=36),group B(GOLD 2 with moderate obstruction,n=37)and group C(GOLD 3 or 4 with obvious obstruction,n=26).The results of chest CT and pulmonary function tests conducted at the first diagnosis and the follow-up,as well as their correlations were analyzed.CT quantitative indicators included the whole lung volume,low-attenuation areas less than-950 percentage(LAA％),total number of vessels per 1 cm2 of lung surface area(Ntotal/LSA),total number of vessels with area less than 5 mm2 per 1 cm2 of lung surface area(N＜5mm2/LSA),the square root of the wall area of a hypothetical airway with a 10 mm internal perimeter(Pi10),the entire volume,wall thickness and wall area percentage(WA％)of airway wall,etc.,while results of pulmonary function tests included the forced expiratory volume in one second(FEV1)after administration of a bronchodilator,forced vital capacity(FVC),the ratio FEV1/FVC and FEV1 expressed as percent predicted(FEV1％).Results Compared with those at the first diagnosis,the follow-up results of FVC,FEV1,FEV1/FVC,Ntotal/LSA and N＜5mm2/LSA were lower,whereas LAA％,Pi10 and entire volume of airway were all higher in each group(all P＜0.05).Compared with those in group A,group B and C had decreased LAA％and increased Pi10,and the magnitude increased with the severity of airflow obstruction(all P＜0.05).LAA％,Pi1o and entire volume of airway wall were negatively correlated with pulmonary function indicators(all P＜0.05),while Ntotal/LSA and N＜5 mm2/LSA were positively correlated with pulmonary function indicators(all P＜0.05).Conclusion CT quantitative parameters,including LAA％,Ntotal/LSA,N＜5mm2/LSA,Pi10 and entire volume of airway wall were related to pulmonary function,which might reflect the longitudinal changes of airways and blood vessels in COPD patients.

Cerebral Glucose Metabolic Features of Parkinson's Disease Based on 18F-FDG PET:A Longitudinal Study / 中国医学影像学杂志

Purpose To establish glucose metabolism patterns of Parkinson's disease(PD)at different periods,and to study the changing pattern of target region of interest(ROI)with the period of time,and then explore the relationship between ROIs and cognitive or motor in different periods.Materials and Methods A total of 42 patients with early-stage PD collected from June 2010 to September 2022 in online data from the markers of Parkinson's progression study which included clinical data,and FDG PET imaging was performed at baseline,12,24,36 and 48 months.The data of 8 healthy volunteers were also obtained from the database,and the time range was the same as that of the above-mentioned PD patients.The longitudinal changes of cerebral glucose metabolism in PD patients and the relationship between PD-associated ROI and movement disorder society-sponsored revision of the unified Parkinson's disease rating scale(MDS-UPDRS)score were evaluated.Results PD was relatively reduced activity located in frontal and parietal association areas and relatively increased activity in the cerebellum,the putamen and the cingulate gyrus.In our study of target ROIs over time,FDG uptake in the caudate nucleus,putamen,pallidum,and cerebellum of patients with PD was initially higher than in the normal group,and subsequently decreased.In contrast,the ROI of PD in the anterior cingulate gyrus,posterior cingulate gyrus,the substantia nigra pars compacta and substantia nigra pars reticulata was initially lower than that in healthy controls and subsequently increased.The putamen,pallidum and caudate nucleus metabolic activity showed a positive correlation in 36 month and MDS-UPDRS scores(r=0.659 5,0.678 7,0.716 7,all P<0.05).The caudate nucleus,putamen and pallidum metabolic activity showed a negative correlation in 24 month and baseline(r=-0.541 8,-0.878 9,-0.887 6,all P<0.05).Conclusion We provide 5-year longitudinal data on changes in 18F-FDG imaging outcomes in early PD.In addition,the glucose metabolic activity of caudate nucleus,putamen and globus pallidus are correlated with MDS-UPDRS scores.

Predictive value of atrial volume and strain parameters for disease progression in patients with different types of atrial fibrillation / 中华超声影像学杂志

Objective:To evaluate the cardiac morphological and functional parameters of patients with persistent atrial fibrillation (per-AF) and paroxysmal atrial fibrillation (PAF) using two-dimensional speckle tracking echocardiography (2D-STE) and real-time three-dimensional echocardiography (RT-3DE), and to explore their predictive value for the occurrence and progression of atrial fibrillation.Methods:A retrospective study was conducted on 30 per-AF patients (per-AF group), 30 PAF patients (PAF group) and 25 non-AF subjects (control group) who underwent echocardiography at Wuhan University People′s Hospital from May 2022 to May 2023. The left/right atrial longitudinal strain of reservoir, conduct and contraction (LASr/RASr, LAScd/RAScd, LASct/RASct), and calculated left atrial stiffness (LASI) were assessed by 2D-STE. Three-dimensional left and right atrial maximum volume index (LAVImax/RAVImax), minimum volume index (LAVImin/RAVImin) and emptying fraction (LAEF/RAEF) were obtained by RT-3DE. Then, patients with atrial fibrillation were divided into the normal LAVI group and enlarged LAVI group, and the differences of atrial strain among each group were compared. ROC curve was used to evaluate the overall diagnostic efficiency and cutoff values of ultrasonic parameters in patients with normal volume of atrial fibrillation. Finally, a multivariate Logistic regression model was established to identify the ultrasonic parameters associated with the occurrence and progression of different types of atrial fibrillation.Results:①Structurally, LAD, RAD and RAVImin in control, PAF and per-AF groups increased gradually, while LAEF and RAEF decreased gradually (all P<0.05). ②In terms of strain, LASr in control, PAF and per-AF groups decreased gradually (all P<0.05); Compared with the control group, LAScd, RASr and RAScd in PAF and per-AF groups were significantly decreased, and LASct and RASct in PAF group were significantly decreased (all P<0.05). ③Compared with the normal LAVI group, the LASr, LAScd and LASct in the enlarged LAVI group were significantly decreased, while LASI was significantly increased (all P<0.05); Compared with control group, the left and right atrial strain parameters in LAVI normal group were decreased, and LASI was increased (all P<0.05). The atrial strain parameter ROC was constructed in all subjects with normal left atrial volume, and RASr was the most sensitive indicator.④Multi-factor Logistic regression analysis showed that LAVImin and RASr were the influence factors of PAF ( OR=1.521, 0.907; 95% CI=1.173-1.972, 0.825-0.998; P=0.002, 0.044), LASr was the influence factor of pre-AF ( OR=0.858, 95% CI=0.802-0.917, P<0.001). Conclusions:2D-STE and RT-3DE can be used to evaluate the structural and functional changes of both atria, especially LAVImin, LASr and RASr, which have certain predictive value for the occurrence and progression of atrial fibrillation.

Association between self-rated health status and mortality riskamong the elderly / 预防医学

Objective@#To investigate the association between self-rated health status and mortality risk, and to evaluate the predictive value of self-rated health status for mortality risk among the elderly.@*Methods@#Based on the China Health and Retirement Longitudinal Study (CHARLS) database, data of sociodemographic information, self-rated health status and mortality of the elderly aged 60 years and older were collected from 2011 to 2018. The association between self-rated health status and mortality risk among the elderly was analyzed using a multivariable Cox proportional risk regression model.@*Results@#Totally 4 850 individuals were included, with an median age of 65 (interquartile range, 8) years. There were 2 485 males (51.24%) and 2 365 females (48.76%). There were 877 individuals (18.08%) rated their health as good, 2 078 individuals (42.85%) as general, 1 895 individuals (39.07%) as poor. A total of 28 955 person-years were followed up, with an average follow-up of 5.97 years per person. There were 855 deaths by the end of follow-up in 2018, and the median survival time was 7 (interquartile range, 3) years. Multivariable Cox proportional risk regression analysis showed that there were interactive effects of age, sex and self-rated health status on mortality, respectively (both P<0.05). The results of gender-stratified analysis showed that there was no significant association between self-rated health status and mortality risk in old women (P>0.05). The mortality risk was higher in old men with poor self-rated health than with good self-rated health (<70 years, HR=5.382, 95%CI: 3.263-8.876; 70 to 79 years, HR=3.536, 95%CI: 1.070-11.686; ≥80 years, HR=3.043, 95%CI: 1.827-5.066).@*Conclusion@#There is an association between self-rated health status and mortality risk among the elderly, the old men with poor self-rated health had a higher mortality risk.

Factors affecting tooth loss among the elderly population in China / 预防医学

Abstract@#To investigate the status and influencing factors of tooth loss among the elderly population in China, so as to provide insights into early prevention of tooth loss.@*Methods@#Based on the Chinese Longitudinal Healthy Longevity Survey (CLHLS), data of the elderly people aged 65 years and older who participated in the survey in 2018 were collected, including demographic information, lifestyle, dietary habits, medical history, number of teeth remaining and self-assessment indicators. The status of tooth loss among the elderly were described based on the standard of 28 teeth, and factors affecting tooth loss were analyzed using a multivariable ordinal logistic regression model.@*Results@#A total of 5 260 people was recruited, including 3 346 males (63.61%) and 1 914 females (36.39%). The median age was 78.00 (interquartile range, 18.00) years. The median number of teeth remaining was 12.00 (interquartile range, 23.00), and the median number of missing teeth was 16.00 (interquartile range, 23.00). Multivariable ordinal logistic regression analysis showed that the elderly who were female (OR=1.270, 95%CI: 1.098-1.470), had advanced age (OR=1.090, 95%CI: 1.083-1.098), lived in rural areas (OR=1.369, 95%CI: 1.165-1.610) and urban areas (OR=1.208, 95%CI: 1.027-1.422), smoked (past, OR=1.471, 95%CI: 1.240-1.746; always, OR=1.545, 95%CI: 1.300-1.838) and brushed teeth less than once a day (OR=1.791, 95%CI: 1.488-2.160) had more missing teeth; while the elderly who had high levels of education (junior high school, OR=0.819, 95%CI: 0.681-0.972; high school, OR=0.626, 95%CI: 0.507-0.771; college and above, OR=0.468, 95%CI: 0.334-0.657), kept physical exercise (OR=0.840, 95%CI: 0.736-0.958) and were overweight/obese (OR=0.868, 95%CI: 0.769-0.980) had less missing teeth.@*Conclusion@#Gender, age, residence, educational level, smoking, physical exercise, teeth brushing frequency and overweight/obese are the influencing factors for tooth loss among the elderly in China.

Neural Representation of Multiple Spatial Scales / 生物化学与生物物理进展

Spatial environment includes multiple scales, which can be specifically divided into operable near-scale figural space, navigable space consisting of single-viewpoint space and environmental space, and large-scale geographic space. It is very important for human and other animal’s daily life to distinguish the spatial environment at different scales. The representation of spatial scale is related to its corresponding functional requirements. The parietal lobe is responsible for the representation of near-scale space. Navigable spatial representation in the hippocampus and cerebral cortex shows a “coarse to fine” gradient along the posterior to anterior axis. However, the scale representation of abstract social space shows a dichotomy. Future research should focus on temporal dynamics of spatial scale representation and the influence of spatial scale on the format of the cognitive map.

Sedentary behavior among medical students: repercussions of the coronavirus pandemic / Conduta sedentária entre estudantes de medicina: repercussões da pandemia do coronavírus

ABSTRACT Introduction: In order to face COVID-19, social restriction measures were adopted that influenced the population's living habits, increasing sedentary lifestyle. Considering the high complexity and dedication required by the Medicine course, it becomes relevant to investigate the effect of the pandemic on the practice of physical exercise and sedentary behavior of these students. Objective: Identify changes in physical activity and sedentary behavior self-reported by medical students in the city of Salvador, Bahia, before and during the self-confinement imposed by the COVID-19 pandemic. Methods: Longitudinal, prospective, quantitative study carried out with regularly enrolled medical students over 18 years of age. A virtual, structured, anonymous, self-completed questionnaire was applied, containing sociodemographic and academic aspects. In addition, the International Physical Activity Questionnaire (IPAQ) was applied in its short version, considering the period before and during the pandemic. Through this, the level of physical activity, sedentary behavior and time spent walking and performing moderate and vigorous activities were measured. Results: 268 medical students were included, predominantly women (65.7%), white (50.0%) and mixed race (38.8%), aged 24.2 ± 5.5 years, single (90.7%), attending the clinical cycle (59.0%), in private institutions (78.4%). No statistically significant differences were identified in the level of physical activity and in the time spent with moderate and vigorous activities. However, there was a reduction in walking time (p<0.00001) and an increase in sedentary behavior (p=0.001) during the COVID-19 pandemic, with the greatest impact among women (p=0.0009). Conclusion: The repercussions of the COVID-19 pandemic have been shown to increase the sedentary behavior of medical students, especially among women, and to reduce activity time spent with walking. Longitudinal studies are needed to analyze the medium and long-term consequences of this change in the healthy lifestyle habits of medical students. Level of evidence II; Comparative prospective study.

Resumen Introducción: Frente al COVID-19 se adoptaron medidas de restricción social que influyeron en los hábitos de vida de la población, aumentando el sedentarismo. Considerando la alta complejidad y la dedicación exigida por la carrera de Medicina, se torna relevante investigar el efecto pandémico sobre la práctica de ejercicio físico y la conducta sedentaria de estos estudiantes. Objetivos: Identificar los cambios en la actividad física y en la conducta sedentaria auto-reportados por los estudiantes de Medicina de la ciudad de Salvador, Bahía, Brasil, antes y durante el auto-confinamiento impuesto por la pandemia de COVID-19. Métodos: Estudio longitudinal, prospectivo, cuantitativo, realizado con estudiantes de medicina regularmente matriculados, mayores de 18 años. Foi aplicado um questionário virtual, estruturado, anónimo, autocompletado, contendo aspectos sociodemográficos e académicos. Além disso, foi aplicado o International Physical Activity Questionnaire (IPAQ), em sua versão curta, considerando o período antes e durante a pandemia. A través de éste, se midió el nivel de actividad física, el comportamiento sedentario y el tiempo dedicado a caminar, así como las actividades moderadas y vigorosas. Resultados: Se incluyeron 268 estudiantes de medicina, predominantemente mujeres (65,7%), blancas (50,0%) y morenas (38,8%), de 24,2 ± 5,5 años de edad, solteras (90,7%), en el ciclo clínico (59,0%), en instituciones privadas (78,4%). No se identificaron diferencias estadísticamente significativas en el nivel de actividad física y el tiempo dedicado a actividades moderadas y vigorosas. Sin embargo, hubo una reducción en el tiempo de caminata (p<0,00001) y un aumento en la conducta sedentaria (p=0,001) durante la pandemia COVID-19, siendo mayor el impacto entre las mujeres (p=0,0009). Conclusión: Las repercusiones de la pandemia COVID-19 se manifestaron en el aumento de la conducta sedentaria entre los estudiantes de medicina, especialmente entre las mujeres, además de la reducción del tiempo de actividad dedicado a caminar. Son necesarios estudios longitudinales para analizar las consecuencias a medio y largo plazo de este cambio en los hábitos de vida saludables de los estudiantes de medicina. Nivel de evidencia II; Estudio Prospectivo Comparativo.

RESUMO Introdução: Foram adotadas medidas de restrição social para o enfrentamento da COVID-19 que influenciaram nos hábitos de vida da população, aumentando o sedentarismo. Considerando a alta complexidade e a dedicação exigida pelo curso de Medicina, torna-se relevante investigar o efeito da pandemia na prática de exercício físico e conduta sedentária desses estudantes. Objetivos: Identificar alterações na atividade física e na conduta sedentária autorrelatadas por acadêmicos de Medicina na cidade de Salvador, Bahia, antes e durante o autoconfinamento imposto pela pandemia de COVID-19. Métodos: Estudo longitudinal, prospectivo, quantitativo, realizado com estudantes de Medicina, maiores de 18 anos, regularmente matriculados. Foi aplicado um questionário virtual, estruturado, anônimo, de autopreenchimento, contendo aspectos sociodemográficos e acadêmicos. Além disso, foi aplicado o International Physical Activity Questionnaire (IPAQ), em sua versão curta, considerando o período antes e durante a pandemia. Através deste, foram mensurados nível de atividade física, conduta sedentária e tempo de realização de caminhada, além de atividades moderadas e vigorosas. Resultados: Foram incluídos 268 estudantes de Medicina, predominantemente mulheres (65,7%), da raça branca (50,0%) e parda (38,8%), com idade de 24,2 ± 5,5 anos, solteiros (90,7%), cursando o ciclo clínico (59,0%), em instituições privadas (78,4%). Não foram identificadas diferenças estatisticamente significantes no nível de atividade física e no tempo despendido com atividades moderadas e vigorosas. Entretanto, houve redução no tempo de caminhada (p<0,00001) e aumento da conduta sedentária (p=0,001) durante a pandemia de COVID-19, sendo o impacto maior entre as mulheres (p=0,0009). Conclusão: Foram demonstradas as repercussões da pandemia de COVID-19 no aumento da conduta sedentária dos estudantes de Medicina, principalmente entre as mulheres, além da redução do tempo de atividade despendido com caminhadas. Estudos longitudinais são necessários para analisar as consequências a médio e longo prazo dessa alteração nos hábitos de vida saudáveis de estudantes de Medicina. Nível de evidência II; Estudo Prospectivo Comparativo.