The Pedagogical Residency Program and the Digital Training of Graduates in Natural Sciences

The immersion of digital technologies in the initial training of Natural Sciences teachers has become even more complex since the beginning of the Covid-19 Pandemic. In this sense, the present study proposed to analyze how digital technologies are present in the training of Natural Sciences teachers. For this, 15 semi-structured interviews were carried out and an online questionnaire was applied to teachers and students of the Biology, Chemistry and Physics subprojects of the Pedagogical Residency Program/Capes (RP/Capes) of the Federal University of Bahia (UFBA). Based on the principles of Critical Discourse Analysis, the reports identified difficulties in problematizing training with digital technologies, in view of the need to restructure the curricular matrices of the degrees, in addition to the already rooted instrumental training of future teachers. In this way, it is essential to expand the promotion of initial teacher training programs, such as PR, regarding the need to remove the instrumentalizing perspective that limits dialogue with technologies, making actions attentive to the potential of such digital spaces. © 2023 Universidade Federal do Rio Grande do Sul, Instituto de Fisica. All rights reserved.

Delayed Extensive Local Reaction to the mRNA-1273 Vaccine against SARS-CoV-2: A Case Report

In response to the COVID-19 pandemic, two mRNA vaccines (Comirnaty and Spikevax) received emergency use authorization from the European Medicines Agency. This case report aimed to report a delayed adverse reaction to the mRNA-1273 vaccine against COVID-19 from a Portuguese vaccination center.A case report was performed with medical observation and reported to the Portuguese Pharmacovigilance System, then investigated based on the WHO-UMC Causality Categories. A 66-year-old female patient with a clinical history of dyslipidemia, essential arterial hypertension, obesity, multinodular goitre and cholecystectomy, who presented delayed large cutaneous hypersensitivity reaction following Spikevax COVID-19 mRNA (mRNA-1273) vaccine administration.Our clinical findings (time and clinical appearance), along with evidence of previously reported histological findings, are strongly suggestive of T-cell-mediated hypersensitivity. There is no contraindication to the inoculation of subsequent doses in patients developing these clinical conditions, and vaccination should continue to be strongly encouraged.

Urban Green Spaces in Brazil: Challenges and Opportunities in the Context of the COVID-19 Pandemic

During the COVID-19 pandemic, urban green spaces were considered less prone to contagion, and thus people adopted them as alternative sites for improving mental health. The One Health concept advocated by health organizations worldwide supports the idea that the well-being of urban residents is strongly linked with physical activity in green areas. As the world grapples with the physical and mental health consequences of the COVID-19 pandemic, it becomes clearer that access to urban green spaces is a human rights issue. This study compared previously-mapped urban green spaces in five metropolitan regions in Brazil with the results of an extensive survey of municipal managers concerning possible increase in demand of population for green spaces. Urban green spaces of over 625 m2 were mapped in 117 municipalities, the total area of 4170 km2 representing 37.4% of the urban spaces analyzed in the five metropolitan regions. Out of these 117 municipalities, 49 had data available concerning demands of green spaces in the pandemic context. Overall, 20 municipalities (representing all five metropolitan regions) stated that there was an increase in visitation in urban green spaces, and 13 more indirectly suggested possible demands. When sustainability transitions are understood as geographical processes that happen in concrete places, urban green spaces then represent real locations where sustainable transitions can begin. The unequal distribution of these spaces also brings into consideration a social justice perspective, as well as aspects of public health that involve climate change resilience and epidemiological risk (SDG 11). © 2023, Scientific Publishing House of the Cardinal Stefan Wyszynski University. All rights reserved.

Factors associated with the SARS-CoV-2 infection among health professionals from university hospitals

Objective: to investigate factors associated with the SARS-CoV-2 infection among health professionals from university hospitals. Method: a multicenter, mixed approach study with concomitant incorporated strategy, carried out with 559 professionals in the quantitative stage, and 599 in the qualitative stage. Four data collection instruments were used, applied by means of an electronic form. The quantitative analysis was performed with descriptive and inferential statistics and the qualitative data were processed by means of content analysis. Results: the factors associated with the infection were as follows: performance of the RT-PCR test (p<0.001) and units offering care to COVID-19 patients (p=0.028). Having symptoms increased 5.63 times the prevalence of infection and adhering to social distancing most of the time in private life reduced it by 53.9%. The qualitative data evidenced difficulties faced by the professionals: scarcity and low quality of Personal Protective Equipment, work overload, physical distancing at work, inadequate processes and routines and lack of a mass screening and testing policy. Conclusion: the factors associated with the SARS-CoV-2 infection among health professionals were mostly related to occupational issues.

Fatores associados a infeccao por SARS-CoV-2 entre profissionais da saude de hospitais universitarios*

Objetivo: investigar fatores associados a infeccao por SARS-CoV-2 entre profissionais da saude de hospitais universitarios. Metodo: estudo multicentrico, de abordagem mista com estrategia incorporada concomitante, realizado com 559 profissionais na etapa quantitativa, e 599 na etapa qualitativa. Foram utilizados quatro instrumentos de coleta de dados, aplicados via formulario eletronico. A analise quantitativa foi realizada com estatistica descritiva e inferencial e os dados qualitativos por meio de analise de conteudo. Resultados: os fatores associados a infecao foram: realizacao de teste "RT-PCR" (p<0,001) e unidades com atendimento a pacientes com COVID-19 (p=0,028). Ter sintomas aumentou em 5,63 vezes a prevalencia de infecao e aderir ao distanciamento social na maior parte do tempo na vida particular reduziu em 53,9%. Dados qualitativos evidenciaram dificuldades enfrentadas pelos profissionais: escassez e baixa qualidade de equipamentos de protecao individual, sobrecarga de trabalho, distanciamento fisico no trabalho, processos e rotinas inadequadas e ausencia de uma politica de triagem e testagem em massa. Conclusao: os fatores associados a infeccao por SARS-CoV-2 entre profissionais da saude foram em sua maioria relacionados a questoes ocupacionais.

PERSPECTIVES ON ENVIRONMENTAL EDUCATION AND ENVIRONMENTAL JUSTICE FOR A LATIN AMERICA AND THE CARIBBEAN POST-COVID-19

Latin America and the Caribbean is between regions the world with the highest number of Covid-19 deaths. What is certain is that some factors allow the continent to suffer more damage and have greater difficulty in facing the pandemic, the objective of this research situated in the field of Fundamentals of Environmental Education is to understand this situation at first, and then seek to point out alternatives for the region. These alternatives are found from the horizon of environmental justice for the post-Covid-19. The study follows a methodological approach of Philosophical Hermeneutics. as perspectives the study points to: adoption of Eco socialism, change in the energy mix;change in consumption practices;change in human-nature relations, new ways of bringing nations together, overcoming the colonialist model;strengthening of potential and overcoming the discourse of poverty;Latin American solidarity as a possibility to overcome social exclusion;the reinvention of more democratic political systems with the effective participation of the population;appreciation of Latin American identity, based on the recognition of Traditional Peoples;and facing the postponement of the discussion on climate change. © 2023, University of Cienfuegos, Carlos Rafael Rodriguez. All rights reserved.

Excavations, evocations and invocations ... or how to deal with the holes in the dirt

In a moment of radical crisis caused by the COVID-19 pandemic institutions, in the face of the many graves opened to bury people whose deaths cannot even be ritualized, a group of four artists-teachers, of different institutions, question themselves about their own holes - the holes in history, in bodies, in living matter. The experience at a debate table with performative contours unfolds in this article, which, by means of a collective and performative writing, has as research subject the performing arts of our time, between the paradox of presence and absence, marked both by the political impacts and by their ability to not lose the power of magic, which connect you to other worlds.

Active learning: a new look at learning organizations

This article aims to analyze the national scientific production on andragogy, active learning and organizational learning, in the period from 2015 to 2021, in order to identify the contribution of distance education (DL) in the learning process to overcome the challenges faced by organizations today. To this end, a systematic literature review was conducted based on the protocol for selecting and analyzing sources defined by Cronnin, et al. (2008). The qualitative and quantitative research was carried out in journals classified as Qualis Capes A1 to B2, in the Web of Science database. Bibliometric mapping was used to analyze the publications and Iramuteq software was used to process the lexical data of the s of the selected articles. The results of the research point to distance education as a potential model for the educational process capable of working on different organizational competencies.

Clinical Features, Laboratory Findings Outcomes in Multisystem Inflammatory Syndrome (Mis-C) Following Covid-19 Infection - a Multicenter, Observational, Ambidirectional Cohort Study in Rio De Janeiro State, Brazil

Objectives: As of March 5th, 2022, around 1.585 cases of MIS-C and 98 deaths (6,4%) were reported in Brazil. The state of Rio de Janeiro State (RJ) having 94 cases (5,9%) and 4 deaths (4,2%)1.Our aim was to evaluate clinical and laboratory features, and management of MIS-C in seven pediatric hospitals in RJ, Brazil. Method(s): Multicenter, observational, ambidirectional cohort study in seven tertiary hospitals in RJ(Brazil), assessing medical charts of pediatric inpatients (0-18 years) diagnosed with MIS-C according to WHO/CDC criteria, from August, 2020 to February, 2022. Descriptive statistics were used to analyze distributions of continuous variables, frequencies, and proportions. Result(s): A total of 112 cases of MIS-C were enrolled. The mean age was 4.2 years and thre was male predominance (59,8%). All cases had a SARS-CoV-2 contact (29.5% close contact;31.3%:positive PCR;serology:43.8%).Only 12.5% had comorbidities. Length of stay (LOS) was 7 days.Median duration of fever was 8 days. Most common symptoms were: rash(67%);gastrointestinal (67%);conjunctivitis (42%);neurological(39.6%);cardiovascular(37.5%);cervical lymphadenopathy (36.6%), and shock/hypotension(28.6%).Co-infection occurred in 3 patients. Forty-four patients fulfilled criteria for Kawasaki disease. Most patients were admitted to PICU(12;62,5%) for amedian of 2 days. Respiratory distress was seen in 18,7%;hypotension:28,6%, and shock in 23,2%. Main laboratory findings were: high C-reactive protein in 95%;D-dimer:77%, anemia:77%, thrombocytosis:63%;transaminitis:43.8%, lymphopenia:38%;hypoalbuminemia:34%;thrombocytopenia: 29%;hypertriglyceridemia:28%, and high pro-BNP in 27%. Echocardiogram was performed in 91/112 patients;abnormal in 70,3%;exhibiting myocardial dysfunction( 25%);pericardial effusion(21%);coronary dilation/aneurysms(11%) and, valvulitis (14.5%). IVIG+corticosteroids (CTC) were administered in 59.8%(67/ 112);18.6%(18/112) IVIG only;10.7%(12/112) CTC only;3.4%(4/112)biologics, and 15(13.3%) received no treatment. ASA low dose in 77.7% (87/112) and moderate/high dose in 34.8%. Oxygen support was needed in 27,7%;vasoactive amines:18,7%;dialysis:5,3%, and transfusion:18,7%.One patient died from a cytokine storm syndrome. Conclusion(s): Our study reports a higher number of MIS-C cases in RJ than the number reported to Brazilian authorities, highlighting underreporting. Our patients were younger, had fewer comorbidities, cardiovascular/gastrointestinal/renal involvement, shortest LOS in ICU, and a higher frequency of myopericarditis.

Interpersonal violence in a city of Parana: a study about the epidemiological profile of victims and characterization of dental trauma

The socioeconomic context and population vulnerability are directly associated with violence in the country. In Brazil, the Criminal Code provides the illicit act and punishes the aggressor who offends the physical aggression from a person. Interpersonal violence is an illegal act and is associated with the vulnerability of victims. Therefore, the study of the epidemiological profile of victims of interpersonal violence is needed to alert the population about their susceptibility. The present study aimed to design the epidemiological profile of victims of bodily injury from interpersonal violence in the region of Maringa, in the state of Parana, and to study the characterization of dental injuries in terms of permanent weakness and deformity. Four thousand nine hundred sixty-two reports performed between 2018 and 2020 were analyzed using descriptive statistics. Data collected included: sex, age, marital status, the region affected by the bodily injury, type of dental trauma, and responses to "weakness" or/and "permanent deformity". During the period studied, there was a prevalence of female victims (57.8%), white skin color (80.2%), aged between 21 and 30 years (24.9%), single (54.9%), and the most affected region was the upper limbs (32.1%). Regarding bodily injuries with dental involvement, 67 cases were reported, male victims were prevalent (60.3%), and dental fracture was highlighted with 54.4% of examined injuries. The implementation of the Forensic Dentistry Centre took place in August 2019 at the Medico-Legal Institute of Maringa. Also, with the interruption of expert activities in 2020 - due to the COVID-19 pandemic - relevant outcomes regarding permanent weakness were observed. The epidemiological profile of victims is characterized by the female sex, white skin color, the age group from 21 to 30 years old, and singles. Regarding dental trauma, male victims, and dental fractures were prevalent. Furthermore, there was an increase in the classification of "permanent weakness", as well as a slight increase in cases of "further assessment required" for permanent deformity.Copyright © 2023 Faculdade de Medicina de Ribeirao Preto - U.S.P.. All rights reserved.

Drug Design against Covid-19: A Remote Teaching Experience in Pharmaceutical Chemistry

Infront of with the difficulties faced in making a new drug available to the population, it is essential to seek ways to simplify the process. In silico methodologies are alternatives to benchtop experiments, being frequently used due to their speed and low cost. The present study aimed to formulate a theoretical-practical activity in the Pharmaceutical Chemistry course, where students applied their knowledge of structural modeling and molecular docking to propose bioactive compounds against molecular targets of the SARS-CoV-2 virus. The class was divided, and each group presented a drug candidate, the precursors being natural molecules. In total, seven derivatives were designed and tested against different macromolecules, and then an in silico prediction of their physicochemical characteristics was performed. The docking results were positive for all derivatives, in terms of binding energy, mainly GEND with -9.0 kcal mol-1. In addition, the prototypes exhibited good interactions with the amino acids of the respective targets, mainly KAED, QUED and GEND, in addition to presenting adequate physicochemical properties for meeting the Lipinski restrictions. Therefore, this study presented at least three potential inhibitors of SARS-CoV-2, showing the importance of using computational tools in drug design and development, as well as in teaching practice.

Evictions and struggle for the right to housing in the pandemic: female resistance in the experience of the Novo Horizonte Occupation

This article had the objective of analyzing the struggle of women for the right to housing in the context of the covid-19 pandemic, in the Novo Horizonte occupation, in Campos dos Goytacazes, RJ, through a reflection on class, race and gender, articulating the theoretical contributions of intersectionality and the theory of social reproduction. For this purpose, a descriptive, bibliographic research was carried out, using the hypothetical-inductive method, as well as field research to collect data on the Novo Horizonte Occupation. With this methodology, it was possible to describe the Novo Horizonte occupation and the need to suspend evictions in times of the covid-19 pandemic, the Judiciary and the legal-political disputes against evictions, the performance of social movements and, above all, the protagonism of women in the struggle for adequate housing. With these premises it was possible to conclude the portrait of urban occupations in Brazil: composed mostly by black women and single mothers. The evictions and forced removals carried out in the Covid-19 pandemic had a profound impact on women, especially black and peripheral women.

Fatigue and sleep in intensive care nursing workers in the COVID-19 pandemic

Objective: To analyze the relationship between fatigue, sleep quality, variables of health and work in intensive care nursing workers during the COVID-19 pandemic. Methods: Cross-sectional, correlational study conducted from July 2020 to February 2021 with a random and probabilistic sample of nurses and nursing technicians from university hospitals in Rio Grande do Sul, Brazil. A sociodemographic/occupational questionnaire, the Fatigue Assessment Scale and the Pittsburgh Sleep Quality Index were used in data collection. The chi-square test, Mann-Whitney U test and the Spearman correlation coefficient were used in the analyzes, adopting a significance level of 5%. Binary logistic regression analysis was performed. Results: Participation of 114 workers. There was prevalence of low fatigue and poor sleep quality. High fatigue was associated with the variables going to work sick and perceiving noise/vibrations as a cause of discomfort. Nursing technicians were associated with poor sleep quality and concern about exposure to chemical substances. Fatigue and sleep quality were moderately and directly correlated. Adjusted analyzes showed that nurses and nursing technicians with high fatigue were four times more likely to have poor sleep quality (OR = 4.86;CI = 1.50-15.75). Conclusion: Fatigue and sleep quality were directly correlated and are associated with individual and work factors. High fatigue increased the chances of having worse sleep quality assessment. Institutional and organizational strategies should be reviewed in order to prioritize the health protection of these nursing workers.

The Negacionismo of Brazilian Government before the Covid- 19 Pandemic Based on the Works of Michael Focault

This study will address discussions about the government of Bolsonaro in order to contribute to debates and reflections on issues involving the order of discourse and the archeology of knowledge from the perspective of Foucault, considering these as thought triggers that operate during the (dis)government policy. The objective of this study is to reflect on the current Brazilian government from the Foucauldian theory, under the negationist and necropolitics aspect that was accentuated in the context of the Covid-19 pandemic. This is a theoretical essay, based on works by Michel Foucault that discuss relevant aspects in their studies on how to think about contemporary reality, the relationship between discourse, ethics and politics from a critical perspective. Thus, with this study it was identified that the existence of the SUS greatly implies in the crossings of the fight against social inequalities and, mainly, in the defense of life and health in the face of the Covid-19 pandemic.

Proposing an #EASIER cardiopulmonary rehabilitation protocol for coronavirus disease 2019 survivors

The economic and social impact that coronavirus disease 2019 (COVID-19) can bring is undeniable since high numbers of active workers in production and service provision are being contaminated. In addition, those infected may have long-term sequelae, impairing their functional capacity, and consequently, their work activities. It considers that intervention in cardiopulmonary rehabilitation is of great importance, especially in the recovery stage, and should be carried out mainly with the aim of improving dyspnea, severe muscle weakness, and fatigue, to promote functional independence, and increase quality of life. Based on the limitations demonstrated in COVID-19 survivors, we developed a protocol based on the acronym #EASIER, which is divided into six phases. Such a study will be able to early identify the impact of COVID-19 in different severities as well as provide subsidies to guide physiotherapists early, through the correct prescription of rehabilitative interventional measures. © 2023 Heart and Mind ;Published by Wolters Kluwer - Medknow.

Conceptualization of Natural Language-Based Product Configurators for New Product Development in Apparel

Digital technologies enable apparel manufacturers to unlock solutions for new product development (NPD) challenges faced during the Covid-19 pandemic. A Product Configurator (PC) is the key to Mass Customization (MC) as it can employ to elicit customer requirements, which is essential in successful NPD. Even though some online PCs exist in apparel retail and product development, no one could gather customer requirements and deploy them in the NPD. This paper conceptualizes a Natural Language Processing (NLP)-based PC on eliciting customer requirements based on a systematic literature review and a basic concept of Design Space Analysis. Finally, it is contended that this knowledge can apply in relevant software development to modernize apparel design, development and online retail. © 2023 The authors and IOS Press.

RNA extraction alternative method for SARS-CoV-2 molecular diagnosis

The devastating COVID-19 outbreak posed serious challenges for the diagnostics laboratories, facing global shortage of reagents and equipment. This study aimed at evaluating an additional RNA extraction method respect to those already recommended by WHO and CDC. A new protocol for RNA extraction from nasopharyngeal swab was set up, adapting a Qiagen kit, and validated on a set of 96 clinical samples. The analysis showed a sensitivity of 94% and a specificity of 97%, but considering samples with Ct< 36.5, the sensitivity and the specificity increased to 100%. The adapted method was also able to detect samples with very low viral load (Ct> 38), indicating that the two approaches can be considered equivalent for the SARS-CoV-2 diagnostics. This extraction method can help in increasing the throughput for SARS-CoV-2 molecular test, even in a low automation setting.

TEACHING-LEARNING RELATIONSHIPS IN THE CONTEXT OF POST-COVID-19 HYBRID EDUCATION

Purposes: This article seeks to understand the perception of the hybrid teaching system in the post-covid 19 context of the teachers of the National Polytechnic Institute. Theoretical reference: the research problematizes the hybrid teaching-learning relationship in the current context, taking as a reference the worsening of the educational crisis caused by the context of the Covid-19 pandemic. Method: From a qualitative approach, a survey was carried out seeking to know the perception of some teachers about hybrid teaching in the context of higher education of the Higher School of Computing of the National Polytechnic Institute. Results and conclusion: The results point to the difficulties encountered in this process, as well as the challenge to strengthen the hybrid skills of the teachers, and the use of teaching methodologies, as well as technologies to design better experiences based on the development of skills of both face-to-face students how much online. The Covid-19 pandemic highlights our educational weaknesses in terms of our study plans, pedagogical projects and didactic strategies for what we find ourselves in face of the need for a curriculum and didactic strategies that prioritize the reality of everyday life, reconozcan and face social and digital inequalities. Therefore, hybrid teaching-learning brings with it a change of paradigms for the teacher. Research implications: The research contributes from its theoretical review with reflections so that we reassess and plan other ways of teaching and learning in the post-covid19 world. Originality/value: The results obtained in this study are unprecedented, innovative and relevant to the scientific community, contributing mainly to the training of educators, especially environmental educators in crisis contexts. © 2023 ANPAD - Associacao Nacional de Pos-Graduacao e Pesquisa em Administracao. All rights reserved.

What changed between the peak and plateau periods of the first COVID-19 pandemic wave? A multicentric Portuguese cohort study in intensive care

Objective: To analyze and compare COVID-19 patient characteristics, clinical management and outcomes between the peak and plateau periods of the first pandemic wave in Portugal. Methods: This was a multicentric ambispective cohort study including consecutive severe COVID-19 patients between March and August 2020 from 16 Portuguese intensive care units. The peak and plateau periods, respectively, weeks 10 - 16 and 17 - 34, were defined. Results: Five hundred forty-one adult patients with a median age of 65 [57 - 74] years, mostly male (71.2%), were included. There were no significant differences in median age (p = 0.3), Simplified Acute Physiology Score II (40 versus 39;p = 0.8), partial arterial oxygen pressure/fraction of inspired oxygen ratio (139 versus 136;p = 0.6), antibiotic therapy (57% versus 64%;p = 0.2) at admission, or 28-day mortality (24.4% versus 22.8%;p = 0.7) between the peak and plateau periods. During the peak period, patients had fewer comorbidities (1 [0 - 3] versus 2 [0 - 5];p = 0.002) and presented a higher use of vasopressors (47% versus 36%;p < 0.001) and invasive mechanical ventilation (58.1 versus 49.2%;p < 0.001) at admission, prone positioning (45% versus 36%;p = 0.04), and hydroxychloroquine (59% versus 10%;p < 0.001) and lopinavir/ ritonavir (41% versus 10%;p < 0.001) prescriptions. However, a greater use of high-flow nasal cannulas (5% versus 16%, p < 0.001) on admission, remdesivir (0.3% versus 15%;p < 0.001) and corticosteroid (29% versus 52%, p < 0.001) therapy, and a shorter ICU length of stay (12 days versus 8, p < 0.001) were observed during the plateau. Conclusion: There were significant changes in patient comorbidities, intensive care unit therapies and length of stay between the peak and plateau periods of the first COVID-19 wave. © 2023 Associacao de Medicina Intensiva Brasileira - AMIB. All rights reserved.

Metabolomic spittle analysis of post COVID-19 patients

Post COVID-19 patients have been suffering from persistent symptoms even after long periods. The physiopathology of these clinical manifestations still has a lack of knowledge. The objective was to evaluate the total expression of metabolites and spittle biological pathways in patients with 60 days post COVID-19. We included 30 post-hospital discharge patients and we compared seven non COVID-19 patients control. All COVID-19 patients were assessed by demographic characteristics, pulmonary function, exercise capacity, quality of life and body composition. The metabolomic analysis was performed in the patient's splits. From the total of post COVID-19 patients, 66% were male, 60+/-14 years. The lean body mass was 30+/-7kg and fat mass 34+/-13kg. Spirometry mean severity showed FVC of 4+/-1L, FEV1 3+/-1L. Pimax and Pemax values were 90+/-31(cmH2O) and 97+/-31(cmH2O), respectively. The quality of life evaluated by the SGRQ questionnaire showed a mean percentage of magnitude of symptoms 32+/-15, activities 41+/-25, impact 13+/-11 and total of 24+/-15. Physical capacity was measured by the distance in the 6MWT, and presented an average of 413+/-131. The metabolomic analysis showed 19 metabolites statistically significant difference between groups. We observed 3 metabolites overexpressed and 16 with lower expression in post COVID19 patients. From those metabolites, we can have attention to Sphinganine(p=0.03), Piperenol A triacetate(p=0.02) and 1-Monopalmitin(p=0.03) were lower expressed in control group. The creatin was one of the non-expressed metabolites in post hospital discharge COVID-19 patients compared to the control group. Thus, metabolomic analysis can demonstrate different metabolites in post COVID-19 patients to answer persistent symptoms.