Evaluation of virtual surgical planning and three-dimensional configurations for reconstruction of maxillary defects using the fibula free flap.

BACKGROUND: Maxillary reconstructive surgery with fibula free flaps (FFFs) is a challenging procedure for head and neck surgeons. However, virtual surgical planning (VSP) and three-dimensional (3D) printing technologies have contributed to improved functional and aesthetic outcomes. The objective of this report is to demonstrate VSP/3D application in reconstruction of maxillary defects using the FFF by describing the different configurations available. We reviewed a series of consecutive cases operated at our institution and considered the management strategy of in-house planning in VSP/3D application. METHODS: In total, 11 cases were included from November 2016 to December 2021. Eight male and three female were included, with a mean age of 55.4 years old (range: 34-74 years old). Maxillary defects were classified according to Brown's Classification: two cases with IIB, one case with IIC, four cases with IID, three cases with III, and one case with IV. Preoperatively, facial computed tomography (CT) and lower extremity computed tomography angiogram (CTA) were performed in all patients. Osteocutaneous FFFs were planned, harvested, and customized according to the VSP/3D guide configuration. VSP and 3D printed cutting guides were performed by an external company in nine cases and were self-planned in three of them. Titanium 3D-printed fixation plates were used in four cases. RESULTS: All flaps survived, and the main reconstructive goals were achieved in 9 cases out of 11. Mean FFF length before osteotomy was 20.0 cm (17.5-22.5 cm). None of the cases experienced flap ischemia or venous congestion. At least one complication occurred in four cases: Prefabricated titanium plate exposure (two cases), loss of donor site skin grafts (one case), and ectropion (one case). One patient underwent a second FFF reconstruction. Two titanium printed plates became exposed after radiotherapy and needed to be removed. Mean follow-up time was 23.5 months (range 6-63 months). Dental rehabilitation was completed in eight of the 11 cases. Regarding functional recovery, five cases underwent delayed osseo-integrated dental implants (ODI), and two cases had immediate ODI procedures. One case was treated with removal dentition. CONCLUSION: VSP/3D printing technology is a new and helpful tool to successful restoration of craniofacial function and aesthetics. It can be used in the broad range of configurations offered by FFFs considering our suggested management strategy.

Screening method for Enzyme-based liquefaction of corn stover pellets at high solids.

Liquefaction of high solid loadings of unpretreated corn stover pellets has been demonstrated with rheology of the resulting slurries enabling mixing and movement within biorefinery bioreactors. However, some forms of pelleted stover do not readily liquefy, so it is important to screen out lots of unsuitable pellets before processing is initiated. This work reports a laboratory assay that rapidly assesses whether pellets have the potential for enzyme-based liquefaction at high solids loadings. Twenty-eight pelleted corn stover (harvested at the same time and location) were analyzed using 20 mL enzyme solutions (3 FPU cellulase/ g biomass) at 30 % w/v solids loading. Imaging together with measurement of reducing sugars were performed over 24-hours. Some samples formed concentrated slurries of 300 mg/mL (dry basis) in the small-scale assay, which was later confirmed in an agitated bioreactor. Also, the laboratory assay showed potential for optimizing enzyme formulations that could be employed for slurry formation.

Cell spheroids as a versatile research platform: formation mechanisms, high throughput production, characterization and applications.

Three-dimensional (3D) cell culture has tremendous advantages to closely mimic thein vivoarchitecture and microenvironment of healthy tissue and organs, as well as of solid tumors. Spheroids are currently the most attractive 3D model to produce uniform reproducible cell structures as well as a potential basis for engineering large tissues and complex organs. In this review we discuss, from an engineering perspective, processes to obtain uniform 3D cell spheroids, comparing dynamic and static cultures and considering aspects such as mass transfer and shear stress. In addition, computational and mathematical modeling of complex cell spheroid systems are discussed. The non-cell-adhesive hydrogel-based method and dynamic cell culture in bioreactors are focused in detail and the myriad of developed spheroid characterization techniques is presented. The main bottlenecks and weaknesses are discussed, especially regarding the analysis of morphological parameters, cell quantification and viability, gene expression profiles, metabolic behavior and high-content analysis. Finally, a vast set of applications of spheroids as tools forin vitrostudy model systems is examined, including drug screening, tissue formation, pathologies development, tissue engineering and biofabrication, 3D bioprinting and microfluidics, together with their use in high-throughput platforms.

Vent-Lock: A 3D Printed Ventilator Multiplexer to Enhance the Capacity of Treating Patients with COVID-19

Mechanical ventilators are essential to patients who become critically ill from acute respiratory distress syndrome (ARDS), and shortages have been reported due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We utilized cost-effective, on-demand 3D printing (3DP) technology to produce critical components for a novel ventilator multiplexer system, Vent-Lock, to split one ventilator or anesthesia gas machine between two patients. FloRest, a novel 3DP flow restrictor, provides clinicians control of tidal volumes and positive end expiratory pressure (PEEP), using the 3DP manometer adaptor to monitor pressures. We tested the ventilator splitter circuit in simulation centers between artificial lungs and used an anesthesia gas machine to successfully ventilate two swines. As one of the first studies to demonstrate splitting one anesthesia gas machine between two swines, we present proof-of-concept of a de novo, closed, multiplexing system, with flow restriction for individualized patient therapy. Our studies underscore that while possible, ventilator multiplexing is a complicated synergy between machine settings, circuit modification, and patient monitoring. Consequently, ventilator multiplexing is reserved only as a last emergency resource, by trained clinicians and respiratory therapists with ventilator operative experience.

DROSOPHILA S2 cell culture in a WAVE Bioreactor: potential for scaling up the production of the recombinant rabies virus glycoprotein.

The transmembrane rabies virus glycoprotein (RVGP) is the main antigen of vaccine formulations used around the world to prevent rabies, the most lethal preventable infectious disease known. The objective of this work was to evaluate the potential of a bioreactor using wave-induced agitation in the initial steps of scaling up the rRVGP production process by a Drosophila melanogaster S2 cell line to produce rRVGP in sufficient quantities for immunization and characterization studies. Taking advantage of some remarkable features recognized in Drosophila S2 cells for scaling the culture process, a robust recombinant lineage (S2MtRVGPH-His) engineered by our group for the expression of rRVGP using a copper-inducible promoter was used in the bioreactor cultures. The WAVE Bioreactor was chosen because it represents an innovative approach to the cultivation of animal cells using single-use technology. For that purpose, we firstly established a procedure for culturing the S2MtRVGPH-His lineage in 100 mL Schott flasks. Using an inoculum of 5 × 105 cells/mL in culture medium (Sf900-III) induced with solution of CuSO4 (0.7 mM) and a convenient pH range (6.2-7.0), optimal parameter values such as time of induction (72 h) and temperature (28 °C) to increase rRVGP production could be defined. This procedure was reproduced in culture experiments conducted in a WAVE Bioreactor™ 2/10 using a 2 L Cellbag. The results in Schott flasks and in WAVE Bioreactor™ were very similar, yielding a maximum titer of rRVGP above of 1 mg.L-1. The immunization study showed that the rRVGP produced in the bioreactor was of high immunogenic quality.

Log law of the wall revisited in Taylor-Couette flows at intermediate Reynolds numbers.

We provide Reynolds averaged azimuthal velocity profiles, measured in a Taylor-Couette system in turbulent flow, at medium Reynolds (7800 < Re < 18000) number with particle image velocimetry technique. We find that in the wall regions, close to the inner and outer cylinders, the azimuthal velocity profile reveals a significant deviation from classical logarithmic law. In order to propose a new law of the wall, the profile of turbulent mixing length was estimated from data processing; it was shown to behave nonlinearly with the radial wall distance. Based on this turbulent mixing length expression, a law of the wall was proposed for the Reynolds averaged azimuthal velocity, derived from momentum balance and validated by comparison to different data. In addition, the profile of viscous dissipation rate was investigated and compared to the global power needed to maintain the inner cylinder in rotation.

Transient expression of rabies virus glycoprotein (RVGP) in Drosophila melanogaster Schneider 2 (S2) cells.

The transient transfection process has been developed to allow rapid production of recombinant proteins. In this paper, we describe the transient expression of recombinant rabies virus glycoprotein (RVGP) in Drosophila melanogaster Schneider 2 (S2) cells. Different cell transfection reagents were evaluated, together with the effects of different cell cultivation procedures on RVGP expression. Yields of RVGP in the range 50-90ng/10(7) cells were obtained in multi-well plate transfection experiments, where it was observed that RVGP expression was linked to the DNA concentration. RVGP expression was 1.3 times higher using 10µg rather than 5µg of DNA. Inhibition of RVGP expression was observed at higher concentrations of DNA, with DNA concentrations above 15µg decreasing RVGP expression 1.5-fold for cells transfected with polyethylenimine (PEI) and 1.6-fold for cells transfected with cationic lipid. The results of shake flask transfection indicated that S2 cells were more effectively transfected in suspension than under static conditions. RVGP yields of 182.2ng/10(7) cells (PEI), 201ng/10(7) cells (calcium phosphate), and 215ng/10(7) cells (cationic lipid) were obtained for S2 cell suspension cultures. The highest volumetric RVGP concentration (309ng/mL) was found for cells transfected with cationic lipid. This value was 1.21 and 1.16 times higher, respectively, than for cells transfected with PEI (253.4ng/mL) and calcium phosphate (237.2ng/mL). There was little effect of transfection on the kinetics of cell growth, with growth rates of 1.12 and 1.19d(-1) for transfected and control cells, respectively. In spinner flasks, the expression of RVGP was 150 and 138ng/10(7) cells for transfection using PEI and calcium phosphate, respectively. A comparison of the different transfection reagents (calcium phosphate, cationic lipid, and cationic polymer) showed no significant differences in RVGP expression when shake flasks were used. Overall, the data indicated that transient expression in D. melanogaster S2 cells is a practical way of synthesizing RVGP for use in structural and functional studies.

Correlação entre achados manométricos e sintomatologia na incontinência fecal / Correlation between manometric findings and symptomatology in fecal incontinence

Foram estudados 92 pacientes com sintomatologia de incontinência fecal, no período de julho de 2005 a fevereiro de 2009. Os sintomas de incontinência foram classificados de acordo com o Cleveland Clinic Incontinence Score e os pacientes foram submetidos à manometria anorretal. Foram avaliados: idade, sexo, cirurgia prévia, sintomatologia e achado manométrico. Observou-se que o aumento da intensidade da sintomatologia de incontinência fecal está relacionado à diminuição progressiva das pressões de repouso. O mesmo não foi constatado com as pressões de contração na amostra estudada.

We have studied 92 patients with fecal incontinence symptoms, from July 2005 to February 2009. They were classified on the Cleveland Clinic Incontinence Score and all of them have undergone on manometric examination. Sex, age, previous surgery, symptomatology, and manometric findings were analyzed. We have concluded that the increase of incontinence symptoms is related to the progressive decrease on resting pressures. The same was not found with squeeze pressures in the studied sample.

Perfuração retal incompleta após enema opaco: relato de caso / Incomplete rectal perforation after barium enema: a case report

O enema opaco, apesar de atualmente apresentar indicações restritas, continua útil na propedêutica radiológica do cólon. A perfuração colorretal é a mais grave complicação do enema opaco, ocorrendo em 0,02 a 0,23 por cento dos exames realizados, com taxa de mortalidade de até 50 por cento. É relatado caso de paciente masculino, 40 anos, há dois meses apresentou dor anal intensa e sangramento durante a realização de enema opaco para investigação etiológica de constipação, com melhora espontânea após um mês. Ao exame proctológico constatou-se infiltração da margem anal, submucosa do canal anal e reto extraperitoneal por sulfato de bário, sem locais de perfuração. O enema opaco trazido pelo paciente e a radiografia simples de pelve após dois meses do exame mostravam perfuração retal incompleta por sulfato de bário. Optado por observação clínica e intervenção cirúrgica se houver complicação. Atualmente o paciente segue em acompanhamento ambulatorial, permanecendo assintomático há 15 meses.

The barium enema, although present indications are currently restricted, is still useful on radiological workup in the colon. Colorectal perforation is the most serious complication of barium enema, occurring at 0.02 to 0.23 percent of examinations performed, with mortality rate of up to 50 percent. We report the case of male patient, 40 years, two months ago had intense anal pain and bleeding during performing of barium enema for etiologic investigation of constipation, with spontaneous improvement after a month. On examination, there was cutaneus and submucosal infiltration of the anus and extraperitoneal rectum by barium sulfate, without perforation. The enema brought by the patient and the radiography of the pelvis after two months of the examination showed incomplete rectal perforation by barium sulfate. Performed clinical observation and surgical intervention only if arises complication. Currently, patient remains asymptomatic for 15 months.

Síndrome de Fournier secundária a adenocarcinoma de próstata avançado: relato de caso / Fournier's syndrome secondary to advanced prostatic adenocarcinoma: case report

A Síndrome de Fournier é uma fasciite necrotizante rapidamente progressiva que acomete a genitália e região perineal. Mesmo com os avanços na terapêutica, a morbidade e a mortalidade desta afecção permanecem elevadas. É relatado caso de paciente masculino, 70 anos, com diagnóstico de adenocarcinoma de próstata avançado. Há um dia com dor e aumento de volume escrotal associado a febre. Ao exame físico, paciente séptico com gangrena gasosa do pênis e escroto; ao toque retal, lesão ulcero-vegetante em parede anterior do reto estendendo-se de 3 a 7 cm da borda anal. Realizado desbridamento cirúrgico, com identificação de fístula reto-escrotal transtumoral. Estudo histo-patológico da lesão retal confirmou infiltração por adenocarcinoma de próstata. Recebeu alta hospitalar no vigésimo dia de internação, atualmente em acompanhamento oncológico ambulatorial.

Fournier's syndrome is a rapidly progressive necrotizing fasciitis affecting the genitalia and perineal region. Even with the advances in therapy, morbidity and mortality of this disease remain high. We report the case of male patient, 70 years old, diagnosed with advanced adenocarcinoma of the prostate. A day with pain and swelling near scrotum associated with fever. The physical examination revealed septic patient with gas gangrene of the penis and scrotum; on digital rectal examination, a vegetative and ulcerated lesion on the anterior wall of the rectum extending from 3 to 7 cm from the anal edge. Performed surgical debridement, with identification of scrotal-rectal fistula transtumoral. Histo-pathological study of the lesion confirmed rectal infiltration by adenocarcinoma of prostate. Was discharged from the hospital on the twentieth day of hospitalization, outpatient cancer currently monitoring.

Recombinant rabies virus glycoprotein synthesis in bioreactor by transfected Drosophila melanogaster S2 cells carrying a constitutive or an inducible promoter.

S2 cell populations (S2AcRVGP2K and S2MtRVGP-Hy) were selected after transfection of gene expression vectors carrying the cDNA encoding the rabies virus glycoprotein (RVGP) gene under the control of the constitutive (actin) or inductive (metallothionein) promoters. These cell populations were cultivated in a 1L bioreactor mimicking a large scale bioprocess. Cell cultures were carried out at 90 rpm and monitored/controlled for temperature (28 degrees C) and dissolved oxygen (10 or 50% air saturation). Cell growth attained approximately 1.5-3 x 10(7)cells/mL after 3-4 days of cultivation. The constitutive synthesis of RVGP in S2AcRVGP2K cells led to values of 0.76 microg/10(7) cells at day 4 of culture. The RVGP synthesis in S2MtRVGP-Hy cell fraction increased upon CuSO(4) induction attaining specific productivities of 1.5-2 microg/10(7) cells at days 4-5. RVGP values in supernatant as a result of cell lysis were always very low (<0.2 microg/mL) indicating good integrity of cells in culture. Overall the RVGP productivity was of 1.5-3mg/L. Our data showed an important influence of dissolved oxygen on RVGP synthesis allowing a higher and sustained productivity by S2MtRVGP-Hy cells when cultivated with a DO of 10% air saturation. The RVGP productivity in bioreactors shown here mirrors those previously observed for T-flasks and shaker bottles and allow the preparation of the large RVGP quantities required for studies of structure and function.

Recombinant rabies virus glycoprotein synthesis in bioreactor by transfected Drosophila melanogaster S2 cells carrying a constitutive or an inducible promoter

S2 cell populations (S2AcRVGP2K and S2MtRVGP-Hy) were selected after transfection of gene expression vectors carrying the cDNA encoding the rabies virus glycoprotein (RVGP) gene under the control of the constitutive (actin) or inductive (metallothionein) promoters. These cell populations were cultivated in a 1 L bioreactor mimicking a large scale bioprocess. Cell cultures were carried out at 90 rpm and monitored/controlled for temperature (28 °C) and dissolved oxygen (10 or 50% air saturation). Cell growth attained ∼1.5–3 × 107 cells/mL after 3–4 days of cultivation. The constitutive synthesis of RVGP in S2AcRVGP2K cells led to values of 0.76 μg/107 cells at day 4 of culture. The RVGP synthesis in S2MtRVGP-Hy cell fraction increased upon CuSO4 induction attaining specific productivities of 1.5–2 μg/107 cells at days 4–5. RVGP values in supernatant as a result of cell lysis were always very low (<0.2 μg/mL) indicating good integrity of cells in culture. Overall the RVGP productivity was of 1.5–3 mg/L. Our data showed an important influence of dissolved oxygen on RVGP synthesis allowing a higher and sustained productivity by S2MtRVGP-Hy cells when cultivated with a DO of 10% air saturation. The RVGP productivity in bioreactors shown here mirrors those previously observed for T-flasks and shaker bottles and allow the preparation of the large RVGP quantities required for studies of structure and function.

Bioreactor culture of recombinant Drosophila melanogaster S2 cells: characterization of metabolic features related to cell growth and production of the rabies virus glycoprotein.

Although several reports have been published on recombinant protein expression using Drosophila cells, information on their metabolism and growth in vitro is relatively scarce. In the present study, we have analyzed the growth and metabolism of transfected S2 cells (S2AcRVGP) in bioreactor cultures with serum-free medium Sf900 II, to evaluate its potential for mass production of a rabies virus glycoprotein (RVGP). Cells were cultured in a 3 l-stirred-tank bioreactor at 28 degrees C with pH controlled at 6.2 and dissolved oxygen at 50% air saturation. The cells attained a specific growth rate and maximum cell density as high as 0.084 h(-1) and 2.3 x 10(7 )cell ml(-1), respectively. The main substrates consumed during this rapid growth phase were glucose, glutamine and proline. An atypical accumulation of ammonia and alanine was observed in the culture medium, up to 62 mM and 47 mM, respectively, but lactate was produced in low levels. After exhaustion of glutamine and proline as energy sources, alanine was consumed and production of ammonia increased. The production of recombinant RVGP reached concentrations as high as 178 mug l(-1). Premature exhaustion of glutamine, serine and cysteine could be related to degradation of the recombinant glycoprotein. In general, the results demonstrated that S2AcRVGP can be considered an effective vehicle for large-scale recombinant glycoprotein expression and that several critical factors of the bioprocess could be optimized to increase the quality and productivity of the RVGP.

Bioreactor culture of recombinant Drosophila melanogaster S2 cells: characterization of metabolic features related to cell growth and production of the rabies virus glycoprotein

Although several reports have been published on recombinant protein expression using Drosophila cells, information on their metabolism and growth in vitro is relatively scarce. In the present study, we have analyzed the growth and metabolism of transfected S2 cells (S2AcRVGP) in bioreactor cultures with serum-free medium Sf900 II, to evaluate its potential for mass production of a rabies virus glycoprotein (RVGP). Cells were cultured in a 3 l-stirred-tank bioreactor at 28 ‹C with pH controlled at 6.2 and dissolved oxygen at 50% air saturation. The cells attained a specific growth rate and maximum cell density as high as 0.084 h−1 and 2.3 ~ 107 cell ml−1, respectively. The main substrates consumed during this rapid growth phase were glucose, glutamine and proline. An atypical accumulation of ammonia and alanine was observed in the culture medium, up to 62 mM and 47 mM, respectively, but lactate was produced in low levels. After exhaustion of glutamine and proline as energy sources, alanine was consumed and production of ammonia increased. The production of recombinant RVGP reached concentrations as high as 178 ƒÊg l−1. Premature exhaustion of glutamine, serine and cysteine could be related to degradation of the recombinant glycoprotein. In general, the results demonstrated that S2AcRVGP can be considered an effective vehicle for large-scale recombinant glycoprotein expression and that several critical factors of the bioprocess could be optimized to increase the quality and productivity of the RVGP.

[Social actors in HIV/AIDS prevention: opposition and interests in educational policy in Mexico, 1994-2000]. / Actores sociales en la prevención del VIH/SIDA: oposiciones e intereses en la política educativa en México, 1994-2000.

Studies and recommendations by health agencies have emphasized the importance of education in HIV-AIDS prevention. Mexico has included topics on sexuality and HIV-AIDS in school programs, triggering resistance by some social actors. The current study seeks to clarify the various positions and interests and their influence on the textbook content. A literature search was conducted on the period during which the last educational reform was implemented in Mexico. The discourse analysis focused on the ethnography of communication, which identified: the various actors' positions, arguments, actions, economic and political power, and relations to others. The results show that those who oppose the inclusion of these themes in the school curriculum base their position on tradition, contrary to modernization and secularization of social life, and that their positions range from refusal to raising conditions. Networks have been formed that provide such groups with significant economic and political power. Government has given in to some demands by partially modifying the textbook contents. The current analysis proposes to reflect on the potential repercussions of such actions on the control of the epidemic.

Actores sociales en la prevención del VIH/SIDA: oposiciones e intereses en la política educativa en México, 1994-2000 / Social actors in HIV/AIDS prevention: opposition and interests in educational policy in Mexico, 1994-2000

Estudios y recomendaciones de organismos sanitarios han resaltado la importancia de la educación en la prevención del VIH/SIDA. En México, se han incluido temas sobre sexualidad y VIH/SIDA en los programas escolares. El hecho motiva resistencias de algunos actores sociales, este trabajo busca clarificar sus posiciones e intereses, y su influencia en los contenidos los libros de texto. Se realizó una investigación documental con fuentes hemerográficas publicadas en el periodo en que se realizó la última reforma educativa. Se hizo un análisis del discurso con el enfoque de la etnografía de la comunicación que identificó: posición de los actores, argumentos, acciones, poder económico y político y relación con otros. Los resultados muestran que los opositores se basan en una ideología de la tradición, contraria a la modernización y secularización de la vida social, sus posiciones varían del rechazo al condicionamiento. Han formado redes que les confieren poder económico y político significativos. El Estado ha cedido a algunas demandas modificando parcialmente los libros. El análisis plantea reflexionar sobre las repercusiones potenciales tales acciones en el control de la epidemia.

Studies and recommendations by health agencies have emphasized the importance of education in HIV-AIDS prevention. Mexico has included topics on sexuality and HIV-AIDS in school programs, triggering resistance by some social actors. The current study seeks to clarify the various positions and interests and their influence on the textbook content. A literature search was conducted on the period during which the last educational reform was implemented in Mexico. The discourse analysis focused on the ethnography of communication, which identified: the various actors' positions, arguments, actions, economic and political power, and relations to others. The results show that those who oppose the inclusion of these themes in the school curriculum base their position on tradition, contrary to modernization and secularization of social life, and that their positions range from refusal to raising conditions. Networks have been formed that provide such groups with significant economic and political power. Government has given in to some demands by partially modifying the textbook contents. The current analysis proposes to reflect on the potential repercussions of such actions on the control of the epidemic.

Performance evaluation of CHO-K1 cell in culture medium supplemented with hemolymph

Desenvolvimento de meios de cultura isentos de soro fetal bovino (SFB) é uma das grandes prioridades de pesquisa em desenvolvimento de processos com célula animal. O objetivo do presente trabalho foi realizar uma análise do potencial de uso da hemolinfa como suplemento do meio utilizado no cultivo da célula animal ancorante CHO-K1. Para isso, foi adicionado 1% v/v de extrato de hemolinfa ao meio DMEM contendo 10% v/v de SFB e 1,0 ou 4,5 g/L de glicose. O cultivo foi realizado em frascos tipo spinner em um ambiente de 10% v/v de CO2, a 37ºC, utilizando o microcarregador Cytodex 1. Comparando os resultados obtidos no ensaio com hemolinfa com um sem hemolinfa pode-se notar uma influência positiva da hemolinfa no cultivo, já que o ensaio com hemolinfa apresentou uma concentração máxima de células 52% maior e uma produtividade máxima de até 40% maior.

Disseminated histoplasmosis

A histoplasmose disseminada é uma doença rara, que apresenta evoluçäo potencialmente fatal, decorrente da deficiência da imunidade celular do hospedeiro, devendo ser relacionada a infecçöes oportunistas. Säo descritos três grupos de possíveis hospedeiros: crianças com imaturidade imunológica, imunossuprimidos e um grupo sem deficiência imune mensurável pelos métodos atuais.