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Background: X-Linked Moesin-Associated Immune Deficiency (X-MAID) is a rare severe combined immunodeficiency (SCID) subtype that can present at any age due to its variability. Depending on severity, patients demonstrate failure to thrive, recurrent bacterial and viral infections, and increased susceptibility to varicella zoster. It has been characterized by marked lymphopenia with hypogammaglobulinemia and impaired T-cell migration and proliferation. Case Presentation: This is a report of a Cuban 7-year-old male with poor weight gain and facial dysmorphia. He had a history of recurrent bacterial gastrointestinal infections and pneumonia beginning at 4 months of age. He additionally had 4-6 upper respiratory tract and ear infections annually. While still living in Cuba, he was admitted for a profound EBV infection in the setting of significant leukopenia. A bone marrow biopsy confirmed no malignancy. After he moved to the United States, his laboratory work-up revealed marked leukopenia with low absolute neutrophil and lymphocyte count with low T and B cells, very low immunoglobulin levels IgG, IgA, and IgM, and poor vaccination responses to streptococcus pneumonia, varicella zoster, and SARS-CoV-2. Genetic testing revealed a missense pathogenic variant c.511C>T (p.Arg171Trp) in the moesin (MSN) gene associated with X-MAID. He was managed with Bactrim and acyclovir prophylaxis, and immunoglobulin replacement therapy, and considered for hematopoietic stem cell transplantation. Discussion(s): Diagnosis of X-MAID should be considered in patients with recurrent infections and profound lymphopenia. As with SCID, early diagnosis and intervention is of utmost importance to prevent morbidity and mortality. This case demonstrates the importance of genetic testing in identifying this disease as it may prompt an immunologist to consider HSCT if conservative management is suboptimal. In the current literature, HSCT appears promising, but the long-term outcomes have yet to be described.Copyright © 2023 Elsevier Inc.
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Intro: With the first case of COVID-19 in Cuba on March 11, 2020, the Center for Genetic Engineering and Biotechnology in Havana began an extensive vaccine program. Two vaccines based on RBD recombinant protein were developed, one for systemic administration "Abdala" and one mucosal vaccine "Mambisa". Abdala received the EUA in July 2021 and "Mambisa" completed its clinical development as a booster dose for convalescent subjects. Method(s): Two doses (25 and 50 microg) and two schedules (0-14-28 and 1-28-56 days) were evaluated in phase I clinical trials with volunteers 19 to 54 years old. The phase II and III clinical trials were also double-blind, randomized, and placebo-controlled, and included respectively 660 and 48,000 volunteers from 19 to 80 years. The anti-RBD titers were evaluated using a quantitative ELISA system developed at the Center for Immunoassay, Havana Cuba, and ELECSYS system from Roche. The RBD to ACE2 plate-based binding competitive ELISA was performed to determine the inhibitory activity of the anti-RBD polyclonal sera on the binding of the hFc-ACE2 coated plates. The neutralization antibody titers were detected by a traditional virus microneutralization assay (MN50). Finding(s): The Abdala vaccine reached 92.28% efficacy. The epidemic was frankly under control in Cuba after the vaccine introduction having reached the highest levels of cases and mortality in July 2021 with the dominance of the Delta strain. The peak of the Omicron wave, unlike other countries, did not reach half of the cases of the Delta wave with a significant reduction in mortality. The mucosal vaccine candidate "Mambisa" completed its clinical development as a booster dose for convalescent subjects reaching the trial end-point. Conclusion(s): Vaccine composition based on RBD recombinant antigen alone is sufficient to achieve high vaccine efficacy comparable to mRNA and live vaccine platforms. The vaccine also protects against different viral variants including Delta and Omicron strains.Copyright © 2023
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The Hermanos Ameijeiras Hospital (HAH) in Havana is the only center performing allogeneic hematopoietic stem cell transplantation (HSCT) in adult patients in Cuba. Because transplants from unrelated donors are not possible due to political restrictions and economic embargo, in 2016 HAH and University of Illinois at Chicago (UIC) started a collaboration to support the training of a physician, annual educational programs and exchange of guidelines and protocols to perform haploidentical transplants. The first haploidentical transplant was performed at HAH in 2016. Because of limited resources, disease risk stratification is based on morphologic assessment, as cytogenetic is tested on an irregular basis. Peripheral blood stem cells (PBSC) were infused based on total nucleated cell count (TNC) due to lack of reagents for flow cytometry. Posttransplant chimerism and CMV monitoring cannot be performed. Transplant activity was stopped in 2020 due to high expenses allocated for COVID19 pandemic in Cuba. From 2016 to 2020, 16 haploidentical HSCT in 15 patients (9 males/ 6 females) were completed at HAH. The median age of patients was 34 years (range:21-54). Diagnoses included: acute leukemia, n=12, myelodysplastic syndrome, n=1, Hodgkin disease, n=1, and severe aplastic anemia, n=1. At the time of transplant, 11 patients were in morphologic remission and 5 had active disease. Conditioning regimens utilized were myeloablative (Flu/Bu) in 10 cases and at reduced intensity (Flu/Cy/ TBI200 +/- ATG) in 6 cases, and GVHD prophylaxis was standard PTCy on D3 and 4, CsA and mycophenolate. The donors were mother (n=10), father (n=1), child (1), or sibling (n=3) and the median age was 48 years (range: 26-68). All patients received fresh stem cells from PBSC(n=13) or bone marrow (n=3). Median cell dose infused was 5.5x108 TNC/kg (range: 2.2-8). All patients but 1 engrafted and median time to neutrophil and platelet engraftment was 17 days (range:12-28) and 16 days (range:11-30), respectively. Acute graft-versus-host disease (GVHD) grade 2-3 occurred in 50% of patients and chronic GVHD in 2 out of 8 that were evaluable. Day 100 and 2-year overall survival rates were 73% and 40%, respectively. With a medium follow-up of 18.8 months (range: 0.3-64), 5 of 15 patients (30%) are alive and complete remission. Causes of death in the remaining 10 patients included relapse of original disease, n= 4;bacterial infection, n=2;brain hemorrhage, n=1;VOD, n=1;graft failure, n=1;and multi-organ failure, n=1. Despite significant difficulties, HAH implemented a haploidentical transplant program for adult patients in Cuba. Among future steps, improving access to molecular testing and using younger donors will be pursued to improve on the results. The partnership between HAH and UIC has been instrumental in building clinical and research capacity and continues to support HAH in its mission to provide care to patients in Cuba.(Figure Presented)Copyright © 2023 American Society for Transplantation and Cellular Therapy
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Introduction: the study of the characteristics of patients with COVID-19 makes it possible to determine risk groups in specific populations and to outline strategies by the institutions to improve the quality of care for these patients. Background: to characterize patients with COVID-19 in Pinar del Rio between March 2020 and March 2021. Methods: an observational, descriptive and cross-sectional study was carried out in patients diagnosed with COVID-19 in the province of Pinar del Rio between March 2020 and March 2021. The sample consisted of 450 patients who met the inclusion and exclusion criteria. Descriptive statistics were used for data analysis. Results: female patients predominated (56%), with a history of arterial hypertension (24,6%). A high incidence of COVID was found in individuals with between two and five chronic non-communicable diseases (40,2%). Of all patients diagnosed with COVID-19, 49% were passive smokers. Conclusions: COVID-19 occurred mainly in patients with several chronic diseases, as well as in those exposed.
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Introduction: universal neonatal hearing screening is a test that enables to identify or suspect hearing loss, performed via habilitation or rehabilitation plan. Background: determine the coverage of universal hearing screening in the epidemiological context of COVID-19 in Guantanamo province, during the period of march 2020 to march 2021. Method: a descriptive, retrospective cross-sectional study was carried out. A total of 5 999 newborns (as Universe) were involved in the study. Variables used were as follow: sex, newborns with or without risk factors, and otoacoustic emissions, which outcomes allowed for the evaluation of universal hearing screening coverage. The standard indicator (95%) and the time at which the first otoacoustic emissions were made were defined. The percentage of newborns detected before one month of life was established as indicator. Results: the 51.1% of the 5 999 newborns were male and 48.3% were female. The 100% of newborns (5 838) without risk factors underwent to the first examination, meanwhile, among those with risk factors (151 newborns) 0.2% (10) could not be tested. Screening of newborns without factors occurred between 1 and 3 days after birth. Screening was never performed after 30 days of birth in those who presented risk factors. Coverage was 99.8% and the reference rate was 0.2%. Conclusions: Universal Hearing Screening Program application in the context of COVID-19 pandemic in Guantanamo province shows a fulfillment in the coverage indicator.
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NEHA offers an exciting opportunity for environmental health professionals to join their private delegation to Havana, Cuba, on Nov 2-6, 2023. They will explore Cuba's rich and varied cultural heritage and go beyond tourist corridors by engaging with local environmental health professionals, officials, engineers, entrepreneurs, musicians, and artists who will offer indepth commentary on health policies, economics, environmental justice, art, history, architecture, and culture. The trip is being organized by CLE Abroad, a provider of customized educational travel programs around the world. The trip is open to all individuals over 18 years.
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The proceedings contain 40 papers. The topics discussed include: sex, bugs microwave attacks: how bad science, mating insects psychogenic illness created an international incident with Cuba;Covid-19 and neuropsychiatry;clinical update on delirium;fibromyalgia and myalgic encephalomyelitis/ chronic fatigue syndrome (ME/CFS): an interoceptive predictive coding model of pain and fatigue expression;when the spark goes out: the neurology of apathy and motivation;is subjective cognitive decline (SCD) a better marker of susceptibility to functional cognitive disorder (FCD) than to neurodegeneration?: the caerphilly prospective study;temporal and spectral dynamics of reward and risk processing in the amygdala revealed with stereo-EEG recordings in epilepsy;a systematic review of extra-motor symptom evaluation in clinical trials for amyotrophic lateral sclerosis;and stimulation of the ventrolateral prefrontal cortex speeds up evidence accumulation in conflictual-uncertain environments.
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This conference proceedings contains 15 articles that discuss various topics in the fields of medicine, psychology, and technology. The articles focus on the adaptation and validation of psychological scales, the effects of COVID-19 on physical and psychological health, the development of biomedical applications, and the evaluation of obstetric risks during the pandemic. It also covers topics related to family influence on child development, coping strategies for infertile couples, and the antioxidant potential of natural products. The pedagogical works included in the proceedings focus on neuropsychological interventions and vulnerability to successful aging and mental health. A literature review delves into the theoretical considerations regarding the study of family, self-determination, and disability in health contexts.
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Aim: To compare following the Cuban Revolution, Cuba's economy and civil society was transformed by the initiation of a program of nationalization and political consolidation. The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the healthcare of its citizens. Other industrialized nations continue to surpass the US in health-related outcomes indicating areas of improvement in its healthcare system. Assessing the successes and failures as well as the advantages and disadvantages of other countries' healthcare systems may be instrumental in the development of modifications to the organization and delivery system of healthcare in the US. This paper aims to report the information attained from previous literature as well as from first-hand observations from a public health trip to Cuba in order to compare the healthcare systems in Cuba and the United States. Materials and Methods: A group of New York University College of Dentistry faculty and students traveled to Cuba in April 2019 for professional research and professional meetings (CFR 515.564). While in Cuba, the researchers took written notes of the lecture-based material and conversations. Upon return to the United States, published literature was searched for the collection of any additional data and all qualitative data and quantitative data was compiled and organized. Since 1959, Cuba has made continuous adjustments and improvements to its universal, free and accessible healthcare system. Results: There have been notable improvements to the country's public health status, such as the implementation of an immunization program and subsequent eradication of communicable diseases, such as polio and rubella. Additionally, the implementation of the National Program on Dentistry guarantees dental care to all Cuban children under the age of 19. Today, the Cuban National Health System (NHS) initiatives have evolved to combat the novel coronavirus (COVID-19) pandemic. Conclusion: Recognizing the advantages as well as the disadvantages of the Cuba's National Health System (NHS) would be useful for future policymakers in the United States. Cuban approaches to health could be tailored to the United States environment to improve healthcare effectiveness and population health status in the future. © 2022 Academy of Advanced Dental Research.
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Introduction: ending 2019, the first reported cases of Covid-19 broke out in Wuhan, China. This disease may affect directly the cardiovascular system or predispose it to be infected by the SARS-CoV-2. Background: to identify the cardiometabolic predictive factors for mortality in patients with SARS-CoV-2/COVID-19 from Santiago de Cuba city in the period May 2020 throughout May 2021. Method: an analytical cohort study was carried out. It was a co-operative research that involved professionals from the Internal Medicine and Intensive Care Services at the Hospital Clinico Quirurgico "Ambrosio Grillo Portuondo", as well as professionals from the Direccion Municipal de Salud in Santiago de Cuba city. A sample of 120 patients was selected for the identification of cardiometabolic predictive factors for mortality. Data analysis was based on the performance of a multivariate model (multivariate logistic regression). Results: throughout the hospitalization period 15 diseases were reported. Female sex was predominant but statistically we can't associate to the deaths these two gender variables. However, age over 60 years, the arterial hypertension, diabetes mellitus and, in a high rank, the vascular involvement, were observed in a strongly association with mortality (p=0.0001). Conclusions: this research allowed the identification of cardiometabolic predictive factors for mortality in COVID-19, where age over 60 years, vascular involvement (cardiogenic shock), hypertension and diabetes mellitus are the main causal factors in the pathophysiological and statistical explanation of mortality.
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Introduction: COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020 due to its complexity and rapid global expansion. Sandino municipality presented its first positive case on October 6, 2020. Objective(s): To characterize the clinical-epidemiological behavior of COVID-19 in Sandino municipality, in 2020. Method(s): A descriptive and cross-sectional research was conducted from March 11 to December 31, 2020. With the information obtained from clinical-epidemiological records, virological results, home and work screening, care for acute respiratory infections in clinics and polyclinics, and the daily reports of the Municipal Health Directorate, a statistical analysis was carried out whose information was inserted in an Excel database. Result(s): The incidence rate was 528.23 per 100 000 population;no deaths. Most of the cases occurred in the city of Sandino. There was a higher frequency of patients in the ages from 41 and 60, and the male sex;while 55.73 % were asymptomatic at diagnosis. The most common symptoms were cough, fever and nasal congestion. Between one and 13 cases per day were diagnosed during the 63 days that there was positivity. Family transmission was 68.23 % and occupational transmission was 50.52 % of cases. Conclusion(s): COVID-19 had a high incidence in Sandino municipality, and this predominated in places with higher population density with intense family and work transmission in a short period of time;also, in the male sex, the age group in working ages, and in the asymptomatic patients.Copyright © 2023, Editorial Ciencias Medicas. All rights reserved.
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Introduction: during the COVID-19 pandemic, new safety measures were implemented in all sectors. However, the Maxillofacial Surgery specialty kept on, where emergency patients were not left unattended. Background: to characterize the maxillofacial emergencies attended at the Hospital Clinico Quirurgico Docente "Celia Sanchez Manduley" in Manzanillo, during the COVID-19 related epidemiological situation. Methods: an observational, descriptive, and cross-sectional study was applied on 358 patients in the period between September 2020 and April 2021. The variables studied were as follow: age groups, sex, month when patients were attended, maxillofacial emergency's motive, therapeutic behavior and patients with COVID-19 related symptoms. Results: the most affected age group was 60 (22.6%), with predominance in male sex (54.2%). Most patients were attended in November and December (20.3%), the predominated maxillofacial emergencies were those associated to maxillofacial trauma (31.8%), followed by facial cellulitis (23.7%). In terms of treatment, the highest percentage of conservative treatment was associated with the medicamentation (88.3%), while wound suturing practice predominated in surgical treatment (18.2%). The symptom with the highest incidence was fever (3.4%). The 61.5% of the maxillofacial surgeons were infected with COVID-19. Conclusions: maxillofacial emergencies are more frequent in males;maxillofacial trauma and facial cellulitis predominate. The maxillofacial surgery service is vulnerable to the coronavirus infection.
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Introduction: post-COVID-19 syndrome is the set of signs and symptoms that develop during or after an infection compatible with COVID-19, that persist for more than 12 weeks and are not explained by an alternative diagnosis. Background: to characterize the clinical-epidemiological behavior of the post-COVID-19 syndrome in patients at the Andres Ortiz Polyclinic. Method: a descriptive and cross-sectional observational study was carried out from October to December 2021, in a population of 51 subjects that was studied in its entirety. The analysis was descriptive. Results: patients with 50-59 years (n = 20;39.2%), female (n = 32;62.7%) predominated. The most frequently affected organ system was the respiratory (n = 19;37.2%), while the symptoms were: chronic fatigue (n = 15;29.4%), shortness of breath (n = 11;21.5%) and cough (n = 8, 15.6%). Among the patients with respiratory (n = 30), cardiovascular (n = 24) and neurological (n = 10) diseases, the most frequent were, respectively: pulmonary fibrosis (n = 17;56.7%), cardiac arrhythmias (n = 11;45.8%) and peripheral neuropathies (n = 5;50%). Conclusions: post-COVID-19 syndrome occurred mainly between the ages of 50 and 59, in female patients, with symptoms of chronic fatigue, shortness of breath and cough, as well as pulmonary fibrosis, cardiac arrhythmias and peripheral neuropathies as main comorbidities.
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Introduction: COVID-19 does not distinguish between age, race or sex. Children and young people constitute a sector of the population that does not escape this reality. Background: to design an educational intervention aimed at raising awareness and preparedness about COVID-19 in adolescents aged 15 to 18 years, admitted to Facultad de Ciencias Medicas de Guantanamo isolation center for suspected cases of SARS-CoV-2. Method: between January 2021 and March 2021, an experimental study of an educational intervention type was carried out. The population was made up of adolescents admitted in the center, all included in the aforementioned age range. A total of 97 intentionally selected adolescents were included in the study. Inquires about the level of information they had on the subject were made, before and after applying the educational intervention. Results: before the implementation of the educational intervention, 50.5% of the adolescents expressed having an insufficient level of information regarding COVID-19, and this proportion decreased to 21.6% after applying it;which meant a 57.2% reduction in adolescents with theoretical deficiencies regarding the subject. The percentage that increased their preparation was 36.9% (p <0.05), which indicated the advantage of implementing the educational intervention. Conclusions: the educational intervention aimed at adolescents suspected of SARS-Cov-2 infection makes it possible to improve knowledge regarding COVID-19.
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Pregnant women generally constitute a group at high risk of infectious diseases due to gestational immunological and physiological changes in their system. That is why the objective of this work is to analyze the implications of the physiological changes of pregnancy in SARS-CoV-2 disease. Physiological changes in pregnant women not only increase their susceptibility to the virus, but also increase the severity of the disease. Changes in the respiratory and immune systems, the role of the placenta in coagulation, and the function of endothelial cells are the physiological changes that most influence the disease. The decrease in lung capacity and the variations that occur in the immune system represent new treatment challenges for pregnant women with COVID-19 disease and therefore new areas of research limited so far.
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Introduction: at present, one of the world's problems it is the health situation. Cuba is not an exception, and the behavior of infestation due to the new outbreak of COVID-19 that is occurring at national level is a great concern. Background: to provide some didactic and pedagogical reflections as part of an adequate school environment that make possible the correct preparation of faculty to teach students in health knowledge and thus mitigating the progressive spread of COVID-19. Method: It was conducted a research at the Universidad de Guantanamo, Universidad de Ciencias Medicas de Guantanamo, and the Instituto Politecnico Agricola de Yateras, from April 2020 throughout January 2021. A total of 30 professors and 30 students (as universe) were involved in this research (10 of each institution). The main variable used was the level of preparation of faculty in school environment and health education. Results: the indicators obtained made it possible to develop the measurement instruments. A qualitative data analysis was made attending to: data reduction, layout and transformation data, as well as the obtained outcomes and conclusions verified. Conclusions: the didactic and pedagogical reflections offered are materialized in a set of guidelines with a methodological approach that guide faculty staff and help to create a positive school environment to strengthen students' health education, based on an exhaustive analysis of the components in the teaching process.
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Introduction: The characteristics of the science produced by the University of Medical Sciences of Havana, published in national student scientific journals, are unknown. Metric studies are ideal tools for approaching problem situations of this nature. Objective: To characterize the scientific production of the University of Medical Sciences of Havana published in Cuban student journals. Methods: A metric, descriptive and cross-sectional study was carried out with 121 articles published in twelve journals between 2017 and 2021. Results: The articles reached 149 citations and 65.8 corrected citations. There was a high Subramanyan index (0.76) and a low index of collaboration between schools (0.16). There were 207 reported authors;two of them were leaders. Original articles predominated (38.8 %). HolCien had the highest Price index (0.87), while the journals 16 de Abril and Universidad Médica Pinareña led, respectively, in number of citations (71) and corrected citations (32.5). The Manuel Fajardo Medical School was the most productive (n=29), while the Calixto García Medical School was the most cited (54 citations). In 2020, the highest number of publications (n=51) and citations (88) was reached, probably as a consequence of COVID-19, which became the main emerging thematic focus of research. Conclusions: The production was characterized by being low, showing a quantitative upward trend, as well as high rates of coauthorship and scientific originality, and by having leading authors. It was weak in terms of collaboration between schools, publication in English and updating of bibliographic references. © 2023, Editorial Ciencias Medicas. All rights reserved.
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Introduction: the value of oxygen as a prognostic maker of mortality due to COVID-19 pneumonia has not been evaluated at the Hospital General Docente "Dr. Agostinho Neto". Background: to identify the values of oxygenation markers for prognosing mortality caused by COVID-19 pneumonia at the Hospital General Docente "Dr. Agostinho Neto" de Guantanamo, Cuba, throughout period 2020-2021. Method: a cohort of 276 patients with COVID-19 pneumonia was studied. Peripheral oxygen saturation (SpO2), arterial oxygen saturation (SaO2), the difference between the oxygen concentration in the alveoli and arterial system (DA-aO2), arterial oxygen pressure ratio (PaO2) and inspired oxygen fraction (FiO2) [PaO2/FiO2] were studied. The association between variables and deceased discharge was determined using the Chi-square technique and the Odds Ratio (OR) calculation. Results: the variable with the highest positive predictive value was SpO2 (87.3%) with a value lower than 90 mmHg at admission. The highest negative predictive value was recorded for the DA-aO2 variable (95.6%), less than 20 mmHg at 48 hours after admission. Attributable risk was higher for PaO2/FiO2 ratio, less than 300 mmHg (0.59), at admission (0.52). Attributable risk percent was higher for the variable DA-aO2 20 mmHg at admission (95.8%) and at 48 hours after admission (95.3%). Conclusions: abnormal DA-aO2, PaO2/FiO2 ratio, SaO2 and SpO2, at admission and 48 hours after admission, are predictive markers of mortality in patients with COVID-19.
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Introduction: The health workers are one of the most prone to becoming infected with COVID-19, due to their exposure during their relationship with patients. Background: To determine the clinical and epidemiological characteristics of COVID-19 in workers of the Pediatric Hospital of Camaguey in the period from January to December 2021. Methods: A descriptive and cross-sectional study was carried out in a universe of 238 workers with a polymerase chain reaction-confirmed diagnosis during the aforementioned period;registered in a database. The variables studied included age group, sex, occupational category, service of origin, clinical manifestations, quarter of the year, and possible source of infection. The data were processed using the statistical program SPSS (Statistical Package for Social Sciences), version 25.0, on a Pentium IV computer. Informed consent and the bioethical principles of confidentiality of information were taken into account in the research. Results: The female sex predominated (54.7%) at ages 50-59 years. They were mostly nursing staff (29.4%), infected during the third trimester (39.9%) in the community (59.3%), presenting symptoms such as nasal discharge (32.8%) and fever (17.6%), working in the pediatric medicine wards (28.2%). Conclusions: Despite the difficult epidemiological situation, the main source of infection was the community. There were no institutional transmission events and there were no deaths.
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Conspiracy theories widely influence our social and political lives. A recent example is the broad impact such theories had on government's efforts to halt the spread of the COVID-19 pandemic. In that context, public's compliance and willingness to get vaccinated was found to be substantially and negatively affected by the belief in conspiracy theories, among various factors. In the present study, we tested whether some countries are more susceptible to conspiracy theories than others. We examined, for the first time, the idea that the degree of intensity of conflict predicts the degree of belief in COVID-19 conspiracy theories. A multilevel analysis across 66 countries (N = 46,450) demonstrated that people living in countries with higher conflict intensity tended to be more susceptible to COVID-19 conspiracy beliefs. These findings are the first large-scale comparative evidence of the profound psychological effects of conflicts on the involved societies. (PsycInfo Database Record (c) 2022 APA, all rights reserved) Impact Statement The belief in COVID-19 conspiracy theories has severe implications on public's health. Thus, it is important to better understand the reasons behind such beliefs. The present study provides new information which helps to better understand the contexts in which conspiracy belief thrive. (PsycInfo Database Record (c) 2022 APA, all rights reserved)