Childhood adversity and mind wandering: the mediating role of cognitive flexibility and habitual tendencies.

ABSTRACTBackground: Initial evidence proposes that exposure to childhood adversity may induce avoidance or withdrawal behaviour. However, it remains unclear whether childhood adversity results in avoidance from externally directed thinking to both deliberate and spontaneous mind wandering, i.e. intentionally or unintentionally diverting attention from ongoing task to task-independent thoughts.Objective: To assess the associations between childhood adversity, and mind wandering, and to evaluate the mediating roles of cognitive flexibility, and habit tendencies.Methods: A total of 601 Chinese subjects (378 females, Mage = 19.37) participated in the current study. The participants completed a series of questionnaires including demographics, childhood maltreatment, cognitive flexibility, habitual tendencies, and mind wandering.Results: Hierarchical regression analyses showed childhood adversity, the control facet of cognitive flexibility, and the automaticity facet of habitual tendencies had significant contributions to deliberate mind wandering (ß = 0.10, ß = -0.40, and ß = 0.06) and spontaneous mind wandering (ß = 0.09, ß = -0.28, and ß = 0.07). Serial mediation analyses revealed that the control and automaticity partially mediated associations between childhood adversity and mind wandering (deliberate mind wandering: 95% CIs = [0.037 0.078], and spontaneous mind wandering: 95% CIs = [0.023, 0.062]).Conclusions: The findings underscore the pivotal role of mediators in delineating the relationship between childhood adversity and mind wandering in everyday life. Interventions geared toward augmenting the control component of cognitive flexibility and regulating the automatic component of habitual tendencies show the potential to ameliorate the propensity of individuals affected by childhood adversity to disengage cognitively from the present moment.

Individuals with greater childhood adversity have higher deliberate and spontaneous mind wandering.Low control and high automaticity contribute to mind wandering.The control and automaticity partially mediate the associations between childhood adversity and mind wandering.

The impact of the COVID-19 pandemic on healthcare services utilization among people living with HIV in Catalonia, Spain: A population-based cohort study.

BACKGROUND: The COVID-19 pandemic disrupted healthcare services usage. We estimated the impact of the COVID-19 pandemic on healthcare services utilization among people living with HIV (PLWH) in Catalonia, Spain. METHODS: We accessed public healthcare usage in HIV units, primary care, hospitals, and emergency departments among 17,738 PLWH in the PISCIS cohort from January 1, 2017, to December 31, 2020. We performed an interrupted time series analysis using the autoregressive integrated moving average to estimate the effect of COVID-19 on medical visits and HIV monitoring among PLWH. RESULTS: A non-significant decrease of 17.1% (95% CI: [-29.4, 0.4]) in overall medical visits was observed during the lockdown, followed by a steady resumption until the end of 2020. Three health facilities presented statistically significant declines in visits during the lockdown: HIV units (-44.8% [-56.7, -23.6]), hospitals (-40.4% [-52.8, -18.1]), and emergency departments (-36.9% [-47.0, -21.9]); thereafter, the visits have begun to increase steadily but not to previous levels as of December 2020. In contrast, primary care visits remained unchanged during the lockdown by 1.9% (95% CI: -13.5, 23.9). CD4 cell (54.2% [95% CI: -64.4, -36.0]) and HIV RNA viral load (53.1% [95% CI: -62.9, -36.1]) laboratory monitoring reduced significantly during the lockdown. CONCLUSION: COVID-19 lockdowns significantly disrupted in-person healthcare services usage among PLWH. The reduction in healthcare utilization however did not affect primary care services. Despite services gradually rebounding to pre-pandemic levels, it is imperative to effectively prepare for future pandemics and implement measures to ensure continuous provision of care to PLWH during pandemic lockdowns.

Isolated distal grade III lateral collateral ligament injury: what is the real clinical impact in professional athletes?

The isolated III grade lateral collateral ligament injuries are rare, and there is limited literature available on their management. We report 3 cases of professional soccer players with isolated distal lateral collateral ligament III grade injury, confirmed by MRI studies. After undergoing MRI examinations, all three players resumed competitive activity without resting and experienced no consequences regarding joint stability. We assessed the significance of the lateral collateral ligament in providing lateral stabilization to the knee joint in professional footballers with clinical tears of the lateral collateral ligament. The other structures of posterolateral area that remain intact contribute to joint stability, and the lateral collateral ligament's extra-articular position appears to expedite the ligament's healing process. Therefore, we propose a possible conservative treatment approach, mostly for professional athletes and adolescent patients, involving a rehabilitation plan without the need for surgery.

Mulheres muçulmanas e cuidado em saúde mental: Reflexões a partir da série 8 em Istambul / Muslim women and mental health care: Reflections from the series Ethos

Resumo Apesar do crescente interesse pela dimensão da religiosidade na área da saúde, muçulmanos têm sido negligenciados pelo campo psi. Por um lado, profissionais pouco conhecem essa religião e seus seguidores; por outro, a população muçulmana cresce tanto pelas reversões quanto por imigração/refúgio, e adentra nas clínicas psicológicas. Para suprir tal descompasso, este artigo tem como objetivo apresentar pontos de atenção a serem considerados quando se trata da saúde mental de mulheres muçulmanas e das especificidades do cuidado direcionado a elas. Para tanto, tomou-se como disparador a série turca 8 em Istambul, que expõe os meandros de um atendimento psicológico a uma mulher muçulmana que usa hijab, o véu islâmico. A análise do corpus fez emergir três eixos reflexivos, que apontam: (1) a necessidade de psicoeducação da comunidade muçulmana diante das tensões e dos estigmas cristalizados; (2) o etnocentrismo e a islamofobia como obstáculos ao processo psicoterapêutico; e (3) a importância da escuta sensível para uma prática psicológica aberta à diversidade cultural-religiosa. Este estudo, em confluência com pesquisas etnográficas conduzidas em campo islâmico brasileiro, permite destacar possibilidades, desafios e aspectos éticos da relação entre religião e cuidado em saúde mental.

Abstract Despite the growing interest in the dimension of religiosity in the health area, Muslims have been neglected in the psychology field. Mental health professionals know little about this religion and its followers. However, the Muslim population is growing, both through reversions and immigration/refuge, leading them to seek psychological care services. To address this divergence, this article aims to present points that should be considered about Muslim women's mental health. To this end, we considered the Turkish series Ethos, which depicts the psychotherapeutic process of a Muslim woman who wears the hijab, the Islamic veil. The analysis of the corpus led to three axes, pointing to (a) the need for psychoeducation of the Muslim community in the face of tensions and stigmas; (b) ethnocentrism and Islamophobia as obstacles to the psychotherapeutic process; and (c) the importance of sensitive listening for a psychological practice open to cultural-religious diversity. The study, in confluence with ethnographic research conducted in the Brazilian Islamic field, allows us to highlight possibilities, challenges, and ethical aspects of the relationship between religion and mental health care.

Cross-cultural adaptation of the Science Motivation Questionnaire II (SMQ-II) for Portuguese-speaking Brazilian secondary school students

Introduction: Science motivation is important for students' scientific literacy. Yet, there is a lack of valid and reliable measurement tools for the Brazilian context. This study presents the Brazilian Portuguese version of the Science Motivation Questionnaire (SMQ-II) and motivational baseline data. Method: The instrument was translated into Brazilian Portuguese using cross-cultural validation procedures. For structural validity evidence, the responses of 646 secondary school students were subjected to exploratory and confirmatory factor analysis, as well as measurement invariance. For reliability evidence, Cronbach's alpha (a) and McDonald's omega (w) were calculated. Students' motivation was analysed using 2 (gender) x 4 (grade levels) x 3 (study modality) MANOVA. Results: 24 items measuring intrinsic motivation, career motivation, grade motivation, and self-efficacy supported a four-factor structure with adequate reliability against the original five-factor structure (self-determination was not salient). Measurement invariance was established across the gender and study modalities, but not for grade levels. Higher-grade level Brazilian students were less motivated, and girls reported higher intrinsic and career motivation, but lower self-efficacy than boys. Conclusion: These findings lay the foundation for the assessment of Brazilian students' science motivation, although they also reveal problems in the latent structure of the SMQ-II and call for the development of instruments rooted in contemporary motivational theories.

Introdução: A motivação científica é importante para a alfabetização científica dos estudantes. No entanto, há uma falta de ferramentas de medição válidas e confiáveis para o contexto brasileiro. Este estudo apresenta a versão em português brasileiro do Questionário de Motivação Científica (SMQ-II) e dados de base motivacionais. Método: O instrumento foi traduzido para o português brasileiro utilizando procedimentos de validação transcultural. Para construir provas de validade, as respostas de 646 alunos do ensino médio foram submetidas à análise exploratória e confirmatória de fatores, bem como invariância de medidas. Para a evidência de confiabilidade, foram calculados o alfa de Cronbach (a) e o ômega de McDonald's (w). A motivação dos estudantes foi analisada usando 2 (gênero) x 4 (notas) x 3 (modalidade de estudo) MANOVA. Resultados: 24 itens medindo a motivação intrínseca, motivação de carreira, motivação de grau e auto-eficácia suportaram uma estrutura de quatro fatores com confiabilidade adequada contra a estrutura original de cinco fatores (a autodeterminação não foi saliente). A invariância da medição foi estabelecida através de gênero e modalidade de estudo, mas não para o nível de nota. Os estudantes brasileiros de grau superior estavam menos motivados, e as meninas relataram maior motivação intrínseca e de carreira, mas menor auto-eficácia do que os meninos. Conclusão: Estas descobertas abrem o caminho para a avaliação da motivação científica dos estudantes brasileiros, mas também revelam problemas na estrutura latente do SMQ-II e exigem o desenvolvimento de instrumentos enraizados em teorias motivacionais contemporâneas.

Manifestaciones gingivales de sífilis secundaria: serie de casos / Gingival manifestations of secondary syphilis: case series

Objetivo: La sífilis es una enfermedad de transmisión sexual con una incidencia creciente a nivel mundial. En la sí- filis secundaria, las lesiones orales son frecuentes, siendo a veces la única manifestación. El objetivo de este artículo es presentar una serie de casos clínicos de sífilis con localización predominante o exclusivamente gingival, destacando las ca- racterísticas clínicas más relevantes para su diagnóstico. Casos clínicos: Esta serie de casos clínicos incluyó nueve casos de sífilis secundaria con manifestaciones gingi- vales. El diagnóstico se realizó mediante pruebas serológicas (VDRL, TPPA, FTA-ABS y MHA-TP), y se describieron le- siones tanto gingivales como extragingivales. En la encía se observó sífilis secundaria afectando principalmente la región anterior ­tanto superior como inferior­, presentándose pla- cas rojas o blancas. Algunos casos también presentaban le- siones en otros sitios intraorales, tenían síntomas como dolor o sensación de ardor, o presentaban enfermedad periodontal dependiente de placa. El diagnóstico diferencial de sífilis se- cundaria gingival con condiciones periodontales inespecíficas es fundamental para un diagnóstico adecuado. Por lo tanto, se debe considerar el diagnóstico de sífilis secundaria cuando se enfrentan casos gíngivo-periodontales atípicos en la práctica diaria (AU)

Aim: Syphilis is a sexually transmitted disease with growing incidence worldwide. In secondary syphilis, oral le- sions are common, sometimes being the only manifestation. Gingival features of syphilis are rare and usually present mul- tiple oral lesions. The aim of this article is to present a series of clinical cases of syphilis with predominantly or exclusively gingival localization, highlighting the most relevant clinical characteristics for its diagnosis. Clinical cases: This clinical case series included nine cases of secondary syphilis with gingival manifestations. The diagnosis was made using serological tests (VDRL, TPPA, FTA-ABS, and MHA-TP), and both gingival and extragingi- val lesions were described. Secondary syphilis was observed in the gum, mainly affecting the anterior region ­both up- per and lower­, depicting red or white plaques. Some cases also presented lesions in other intraoral sites, had symptoms such as pain or burning sensation, or showed plaque induced periodontal disease. The differential diagnosis of second- ary syphilis considering non-specific periodontal conditions with gingival involvement is essential for a proper diagnosis. Thus, the diagnosis of secondary syphilis should be consid- ered when dealing with atypical gingivo-periodontal cases in everyday practice (AU)

Cicatrização de feridas crónicas tratadas com oleorresina de copaíba / Chronic wound healing with copaiba oleoresin application / Cicatrización de heridas crónicas tratadas con oleorresina de copaiba

Resumo Enquadramento: As feridas crónicas representam um problema crescente de saúde em diversos países. Estudos etnobotânicos e pré-clínicos sugerem que a oleorresina de copaíba (Copaífera sp.) possui propriedades cicatrizantes. Objetivo: Avaliar a aplicação clínica da oleorresina de copaíba na cicatrização de feridas crónicas. Metodologia: Estudo retrospectivo de série de casos composta por 6 participantes com feridas crónicas tratadas com: oleorresina de copaíba a 7% com óleo de girassol ou creme de copaíba a 10%. O desfecho primário foi a percentagem de redução da área lesada ao final do seguimento. Resultados: Idade média dos participantes foi 54,5 (DP = 11,5) anos. As causas das feridas foram vasculares (n = 3), cirúrgicas (n = 2) e traumáticas (n = 1). Todos os participantes tiveram redução da área lesada variando entre 15,5% a 100%, durante o seguimento (8 a 15 semanas). Nenhuma complicação foi observada. Conclusão: O tratamento com a oleorresina de copaíba mostrou-se uma opção efetiva e segura no tratamento de feridas crónicas.

Abstract Background: Chronic wounds represent a growing health problem in several countries. Ethnobotanical and preclinical studies suggest that copaiba oleoresin (Copaifera sp.) has healing properties. Objective: To evaluate the clinical application of copaiba oleoresin in chronic wound healing. Methodology: Retrospective case series study consisting of 6 participants with chronic wounds treated with 7% copaiba oleoresin with sunflower oil or 10% copaiba ointment. The primary endpoint was the percentage reduction in wound area at the end of follow-up. Results: Mean age of participants was 54.5 (SD = 11.5) years. The causes of wounds were vascular (n = 3), surgical (n = 2), and traumatic (n = 1). All participants had a reduction of the wound area ranging from 15.5% to 100% during the follow-up (8 to 15 weeks). No complications were observed. Conclusion: Treatment with copaiba oleoresin proved to be an effective and safe option in chronic wound treatment.

Resumen Marco contextual: Las heridas crónicas representan un problema sanitario creciente en varios países. Estudios etnobotánicos y preclínicos sugieren que la oleorresina de copaiba (Copaífera sp.) tiene propiedades cicatrizantes. Objetivo: Evaluar la aplicación clínica de la oleorresina de copaiba en la cicatrización de heridas crónicas. Metodología: Estudio retrospectivo de serie de casos compuesta por 6 participantes con heridas crónicas tratadas con oleorresina de copaiba al 7% con aceite de girasol o crema de copaiba al 10%. El criterio de valoración primario fue el porcentaje de reducción de la zona lesionada al final del seguimiento. Resultados: La edad media de los participantes fue de 54,5 (DP = 11,5) años. Las causas de las heridas fueron vasculares (n = 3), quirúrgicas (n = 2) y traumáticas (n = 1). Todos los participantes presentaron una reducción de la zona lesionada que osciló entre el 15,5% y el 100% durante el seguimiento (de 8 a 15 semanas). No se observaron complicaciones. Conclusión: El tratamiento con oleorresina de copaiba ha demostrado ser una opción eficaz y segura en el tratamiento de heridas crónicas.

Evaluating the impact of private land conservation with synthetic control design.

Programs to protect biodiversity on private land are increasingly being used worldwide. To understand the efficacy of such programs, it is important to determine their impact: the difference between the program's outcome and what would have happened without the program. Typically, these programs are evaluated by estimating the average program-level impact, which readily allows comparisons between programs or regions, but masks important heterogeneity in impact across the individual conservation interventions. We used synthetic control design, statistical matching, and time-series data to estimate the impact of individual protected areas over time and combined individual-level impacts to estimate program-level impact with a meta-analytic approach. We applied the method to private protected areas governed by conservation covenants (legally binding on-title agreements to protect biodiversity) in the Goldfields region of Victoria, Australia using woody vegetation cover as our outcome variable. We compared our results with traditional approaches to estimating program-level impact based on a subset of covenants that were the same age. Our results showed an overall program-level impact of a 0.3-0.8% increase in woody vegetation cover per year. However, there was significant heterogeneity in the temporal pattern of impact for individual covenants, ranging from -4 to +7% change in woody vegetation cover per year. Results of our approach were consistent with results based on traditional approaches to estimating program-level impact. Our study provides a transparent and robust workflow to estimate individual and program-level impacts of private protected areas.

Evaluación del impacto del suelo privado de conservación con diseño de control sintético Resumen Los programas de protección de la biodiversidad en suelo privado se utilizan cada vez más en todo el mundo. Para entender la eficacia de estos programas, es importante determinar la diferencia entre el resultado del programa y lo que habría ocurrido sin él. Normalmente, estos programas se evalúan estimando el impacto medio a nivel de programa, lo que permite fácilmente las comparaciones entre programas o regiones, pero oculta una importante heterogeneidad en el impacto entre las intervenciones individuales de conservación. Utilizamos un diseño de control sintético, un emparejamiento estadístico y datos de series temporales para estimar el impacto de las áreas protegidas individuales a lo largo del tiempo y combinamos los impactos a nivel individual para estimar el impacto a nivel de programa con un enfoque meta-analítico. Aplicamos el método a áreas protegidas privadas regidas por acuerdos de conservación (acuerdos con vínculos jurídicos sobre la titularidad para proteger la biodiversidad) destinados a mejorar la cubierta vegetal leñosa en la región de Goldfields de Victoria, Australia. Comparamos nuestros resultados con los métodos tradicionales de estimación del impacto a nivel de programa basados en un subconjunto de pactos de la misma antigüedad. Nuestros resultados mostraron un impacto global a nivel de programa de un aumento del 0.3-0.8% de la cubierta vegetal leñosa al año. Sin embargo, hubo una heterogeneidad significativa en el patrón temporal del impacto para los pactos individuales, que osciló entre −4 y +7% de cambio en la cubierta vegetal leñosa por año. Los resultados de nuestra estrategia fueron consecuentes con los resultados basados en las estrategias tradicionales usadas para estimar el impacto a nivel de programa. Nuestro estudio proporciona un flujo de trabajo transparente y sólido para estimar el impacto individual a nivel de programa de las áreas protegidas privadas.

Efficacy of eye movement desensitization and reprocessing therapy for fear of cancer recurrence among cancer survivors: a randomized single-case experimental design.

Background: Fear of cancer recurrence (FCR) is one of the greatest problems with which cancer survivors have to deal. High levels of FCR are characterized by intrusive thoughts about cancer-related events and re-experiencing these events, avoidance of reminders of cancer, and hypervigilance, similar to post-traumatic stress disorder (PTSD). Eye movement desensitization and reprocessing (EMDR) therapy focuses on these images and memories. It is effective in reducing PTSD and may be effective in reducing high levels of FCR.Objective: The aim of the present study is to investigate the effectiveness of EMDR for severe FCR in breast and colorectal cancer survivors.Method: A multiple-baseline single-case experimental design (n = 8) was used. Daily repeated measurements for FCR were taken during the baseline phase and treatment phase, post-treatment, and at the 3 month follow-up. Participants answered the Cancer Worry Scale (CWS) and the Fear of Cancer Recurrence Inventory, Dutch version (FCRI-NL) five times, i.e. at the start and at the end of each phase (baseline, treatment, post-treatment, and follow-up). The study was prospectively registered at clinicaltrials.gov (NL8223).Results: Visual analysis and effect size calculation by Tau-U were executed for the daily questionnaire on FCR. The weighted average Tau-U score was .63 (p < .01) for baseline versus post-treatment, indicating large change, and .53 (p < .01) between baseline and follow-up, indicating moderate change. The scores on the CWS and FCRI-NL-SF decreased significantly from baseline to follow-up.Conclusion: The results seem promising for EMDR therapy as a potentially effective treatment for FCR. Further research is recommended.

Patients who experience high fear of cancer recurrence (FCR) often have intrusive memories and images about (future) cancer-related events.Eye movement desensitization and reprocessing (EMDR) therapy can focus on these intrusions.EMDR therapy is found to be a promising therapy for patients experiencing high FCR.

The Syzygy, Reformulation and New Perspectives: Dreams, Anima-Animus and Gender.

The main objective of this qualitative and quantitative research paper is to explore the occurrences and relations of the anima, animus and androgynous in dreams, with particular emphasis on the consideration of the androgynous in the human psyche. The sample consists of 9 series of dreams (141 dreams in total), from 9 dreamers, 7 women (female sex/gender) and 2 men (male sex/gender), aged 25-57, heterosexual, undergoing Jungian psychotherapy, and presenting couple-related themes. Statistical results and qualitative analysis offer new input for the re-vision of the classical anima-animus model, and the addition of in-depth explorations into the androgynous, paving the way for a new model of psychopathology and psychotherapeutic clinical work, in transition.

L'objectif principal de cette étude qualitative et quantitative est d'explorer les apparitions de l'anima, l'animus et l'androgyne dans les rêves, ainsi que les relations entre ces termes, avec un intérêt tout particulier pour l'androgyne dans la psyché humaine. L'échantillon est composé de 9 séries de rêves (au total 141 rêves), de 9 rêveurs dont 7 femmes (sexe et genre féminin) et 2 hommes (sexe et genre masculin) d'âge entre 25 et 57 ans, hétérosexuels, en analyse Jungienne, et montrant des thèmes en rapport avec le couple. Les résultats statistiques et l'analyse qualitative apportent de nouveaux éléments pour la ré-vision du modèle classique anima-animus, et pour l'ajout de recherches approfondies en ce qui concerne l'androgyne. Ceci afin de préparer le chemin pour un nouveau modèle de psychopathologie et de travail clinique de psychothérapie, en transition.

El objetivo principal de este trabajo de investigación cualitativa y cuantitativa es explorar las ocurrencias y relaciones del ánima, ánimus y andrógino en los sueños, con particular énfasis en la consideración del andrógino en el psiquismo humano. La muestra consiste en 9 series de sueños (141 sueños en total), de 9 soñadores, 7 mujeres (sexo/género femenino) y 2 hombres (sexo/género masculino), con edades comprendidas entre 25 y 57 años, heterosexuales, sometidos a psicoterapia junguiana, y que presentan temas relacionados con la pareja. Los resultados estadísticos y el análisis cualitativo ofrecen nuevas aportaciones para la revisión del modelo clásico ánima-ánimus, junto a nuevas exploraciones en profundidad sobre lo andrógino, allanando el camino para un nuevo modelo de psicopatología y trabajo clínico psicoterapéutico, en transición.

Una mirada a las series de casos y sus unidades de análisis

Las series de casos constituyen un tipo particular de estudio de uso muy frecuente en la investigación clínica. En este artículo se pretende resaltar la utilidad y plena vigencia de estos estudios como propuestas de proyectos de terminación de la especialidad, así como abordar sus particularidades más importantes en la delimitación de sus unidades de análisis. Cuando son bien realizadas, estas investigaciones constituyen una excelente fuente de actualización del conocimiento médico y una magnífica oportunidad para que los investigadores jóvenes se entrenen en el campo de la investigación científica.

Case series are a particular type of study that is very frequently used in clinical research. This article intends to highlight the usefulness and full validity of these studies as proposals for completion projects of the specialty, as well as to address their most important particularities in the delimitation of their analysis units. When they are well carried out, these researches constitute an excellent source of updating medical knowledge and a magnificent opportunity for young researchers to train in the scientific research field.

Saúde mental de idosos: uma análise da série Unidade Básica (2016) / Mental health of older adults: an analysis of the series Unidade Básica(2016) / Salud mental del las personas mayores: un análisis de la serie Unidade Básica (2016)

Este artigo tem o objetivo de analisar dois episódios da primeira temporada da Unidade Básica (2016), a fim de identificar sentidos sobre a saúde mental de idosos. Esta série televisiva foi divulgada pela Universal Channel e escrita por Helena Petta, Newton Cannito e Ana Petta. Apenas dois episódios compõem o corpus desta pesquisa; os outros foram desconsiderados por não abordarem o tema. O primeiro trata de Vilma, uma idosa que abandonou o autocuidado por causa da depressão, e o quarto fala sobre Eraldo, um idoso que ficou depressivo em razão de problemas financeiros, amorosos e alcoólicos. A análise de narrativas será utilizada como metodologia, possibilitando a identificação e a interpretação crítica dos sentidos sobre idosos e saúde mental. De forma geral, os resultados revelaram que os episódios não seguem uma visão holística, desconsiderando, portanto, a necessidade de cuidar da saúde física e mental das pessoas idosas para lhes proporcionar bem-estar.

This article aims to analyze two episodes of the first season of Unidade Básica (2016) in order to identify meanings about the mental health of older adults. This series was broadcast by Universal Channel and written by Helena Petta, Newton Cannito and Ana Petta. Only two episodes compose the corpus of this research; the others were disregarded because they do not deal with the theme. The first episode narrated the story of Vilma, an older woman who was depressed and then abandoned self-care. The fourth episode was about Eraldo, an older man who became depressed due to his financial, love and alcoholic problems. The narrative analysis was used as a methodology, enabling the identification and critical interpretation of meanings about older people and mental health. In general, the results reveal that the episodes do not follow a holistic view, disregarding the need to take care of physical and mental health to provide the well-being of them.

Este artículo tiene como objetivo analizar dos episodios de la primera temporada de Unidade Básica(2016) con el fin de identificar significados sobre la salud mental de los adultos mayores. Esta serie fue transmitida por Universal Channel y escrita por Helena Petta, Newton Cannito y Ana Petta. Sólo dos episodios constituyen el corpus de esta investigación; los demás fueron descartados por no retratar el tema. El primer episodio narra la historia de Vilma, una mujer la tercera edad que abandonó el autocuidado a causa de su estado de depresión. El cuarto episodio fue sobre Eraldo, un hombre también de la tercera edad, que se deprimió por problemas económicos, amorosos y alcohólicos. Se utilizó como metodología el análisis narrativo, que permitió la identificación e interpretación crítica de significados sobre las personas mayores y la salud mental. En general, los resultados revelan que los dos episodios no siguen una visión holística, desconociendo la necesidad de cuidar de la salud física y mental para proporcionar bienestar a las personas mayores.

De que morrem as crianças de 5 a 14 anos no estado do Rio de Janeiro? Análise do período 2000-2019 / What do children aged 5 to 14 years die from in the state of Rio de Janeiro, Brazil? Trend analysis of the period 2000-2019

Resumo Objetivou-se investigar a magnitude e a tendência da mortalidade de crianças de 5 a 14 anos por causas, no estado do Rio de Janeiro, de 2000 a 2019. Estudo ecológico de tendência temporal utilizando dados do Sistema de Informações sobre Mortalidade (SIM). Calcularam-se taxas de mortalidade por 100 mil crianças, por capítulos, grupos e categorias (CID-10). Estimou-se a série temporal por regressão joinpoint. As taxas de mortalidade de 10 a 14 anos foram superiores às da faixa de 5 a 9 anos. As cinco principais causas foram as mesmas de 5 a 14 anos, com diferente ordem de importância. As duas principais foram causas externas e neoplasias (31% e 15% para 5 a 9 anos; 45% e 11% para 10 a 14 anos). De 5 a 9 anos, a tendência da mortalidade teve declínio anual (8%) entre 2011 e 2015. De 10 a 14 anos, o declínio anual foi 1,3%, de 2000 a 2019. A mortalidade por causas externas decresceu em ambas as faixas, menos para a categoria "Agressão por arma de fogo" (meninos,10-14 anos) e "Afogamento" (meninos, 5-9 anos). A mortalidade por neoplasias ficou estável para todos. Doenças infecciosas e respiratórias decresceram de forma diferenciada entre os grupos. A maioria das causas de morte é evitável ou tratável, apontando necessidade de investimentos em saúde e intersetoriais.

Abstract This study investigated the magnitude and trends of cause-specific mortality among children 5 to 14 years of age in the state of Rio de Janeiro (RJ) from 2000 to 2019. We performed an ecological study, using data from the Mortality Information System (MIS). We calculated mortality rates per 100,000 children by chapters, groups, and categories of causes of death (ICD-10). Trends were estimated by joinpoint regression. Mortality rates among children aged 10 to 14 years were higher than those among children 5 to 9. The five leading causes of death were the same in both age groups, but they ranked differently. The two leading ones were external causes and neoplasms (31% and 15% among children aged 5 to 9 years; 45% and 11% among children aged 10 to 14 years). Among children 5 to 9 years, the mortality trend showed an annual decline (8%) from 2011 to 2015. Among children aged 10 to 14 years, the annual decline was 1.3% from 2000 to 2019. Mortality due to external causes decreased in both age groups, except for the category "Assault by unspecified firearm" (boys, 10 to 14 years) and "Unspecified drowning and submersion" (boys, 5 to 9 years). Mortality caused by neoplasms remained steady in both age groups. Infectious and respiratory diseases decreased differently between the two groups. Most causes of death are preventable or treatable, indicating the need for health and intersectoral investments.

O crime como ato perverso: uma análise das cartas de assassinos seriais / El crimen como un acto perverso: un análisis de cartas de asesinos en serie / Crime as a perverse act: analysis of letters from serial killers

RESUMO. Este trabalho se insere no campo teórico da psicanálise e tem por objetivo discutir, a partir do conceito de perversão, a relação entre o ato perverso e os assassinatos em série, através das comunicações que certos autores desse tipo de crime realizaram com a mídia e com as forças da lei. Para a realização desse objetivo foi feita uma análise de conteúdo, segundo Bardin (2011), em 35 cartas enviadas por sete assassinos em série diferentes para a grande mídia ou para a polícia. Como resultado, encontra-se o fato de que a estrutura desses documentos é bastante similar e apresentam descrições de seus crimes, seus estados mentais, além de ameaças à população e um deboche direcionado às autoridades e forças policiais. Por fim, nota-se que a estrutura do ato perverso, conforme pensada por Freud e Lacan, está presente nas cartas estudadas, que pertencem a épocas e lugares distintos, e cujos autores não tiveram contato direto entre si.

RESUMEN. Este trabajo es parte del campo teórico del psicoanálisis y tiene como objetivo identificar los comportamientos comunes que están presentes en diferentes actos perversos, más específicamente en las comunicaciones que los asesinos en serie llevan a cabo con los medios de comunicación y las fuerzas de la ley. Para lograr este objetivo, se realizó un análisis de contenido, según Bardin (2011) sobre 35 cartas enviadas por siete asesinos en serie diferentes a los principales medios de comunicación o la policía. Como resultado, existe el hecho de que la estructura de estos documentos es bastante similar y presenta descripciones de sus crímenes, sus estados mentales, además de las amenazas a la población y un libertinaje dirigido a las autoridades y las fuerzas policiales. Finalmente, se observa que la estructura del acto perverso, como lo piensan las teorías de Freud y Lacan, tiende a repetirse en los sujetos estudiados, que pertenecen a diferentes tiempos y lugares y que no tuvieron contacto directo entre sí.

ABSTRACT This work is part of the theoretical field of psychoanalysis and aims to discuss, from the concept of perversion, the relationship between the perverse act and serial murders, through the communications that certain authors of this type of crime made with the media and with the forces of the law. To achieve this objective, a content analysis was carried out, according to Bardin (2011), on thirty-five letters sent by seven different serial killers to the mainstream media or the police. As a result, there is the fact that the structure of these documents is quite similar and presents descriptions of their crimes, their mental states, in addition to threats to the population and a debauchery directed at the authorities and police forces. Finally, it is noted that the structure of the perverse act, as thought by the theories of Freud and Lacan, is present in the studied letters, which belong to different times and places, and whose authors had no direct contact with each other.

Time trend of infant mortality in Pernambuco, 2001-2019: a population-based ecological study / Tendência temporal da mortalidade infantil em Pernambuco, 2001-2019: um estudo ecológico de base populacional

Abstract Objectives: to analyze the temporal trend and spatial distribution of infant mortality in Pernambuco from 2001 to 2019. Methods: an ecological study involving all deaths in children under one year of age living in the state. Data were collected from the Mortality Information System and the Live Birth Information System. Four mortality rates were calculated and the temporal analysis was performed by applying the regression model by inflection points of the rates at different spatial levels. Results: 47,949 deaths were recorded, of which 51.0% (n=24,447) occurred in the first six days of life. A statistically significant downward trend was observed in all the rates analyzed (-4.5%/year in overall mortality, -3.6%/year in early neonatal mortality, -1.9%/year in the late neonatal component, and -6.3%/year in the post-neonatal component). Additionally, 64.3% of the municipalities (n=119) showed a declining trend in the overall infant mortality rate. Less than 50% of the municipalities showed a downward trend in early neonatal and late neonatal mortality (41.08%; n=76 and 43.2%; n=80, respectively). In post-neonatal mortality, 57.3% (n=106) showed decreasing trends. Conclusions: there was a temporal trend of decline in overall infant mortality, although there is an important portion of municipalities with a stationary trend, justifying the need to reduce social inequalities and geographical asymmetries.

Resumo Objetivos: analisar a tendência temporal e a distribuição espacial da mortalidade infantil em Pernambuco no período de 2001 a 2019. Métodos: estudo ecológico envolvendo todos os óbitos em crianças menores de um ano residentes no estado. Os dados foram coletados no Sistema de Informações sobre Mortalidade e no Sistema de Informação sobre Nascidos Vivos. Foram calculados quatro coeficientes de mortalidade e a análise temporal foi realizada aplicando o modelo de regressão por pontos de inflexão dos coeficientes em diferentes níveis espaciais. Resultados: foram registrados 47.949 óbitos, dos quais 51,0% (n=24.447) ocorreram nos seis primeiros dias de vida. Foi observada tendência de declínio estatisticamente significativo em todos os coeficientes analisados (-4,5%/ano na mortalidade geral, -3,6%/ano na neonatal precoce, -1,9%/ano no componente neonatal tardio e de -6,3%/ano no componente pós-neonatal). Adicionalmente, 64,3% dos municípios (n=119) apresentaram tendência de declínio no coeficiente de mortalidade infantil geral. Menos de 50% dos municípios apresentaram tendência de redução na mortalidade neonatal precoce e neonatal tardia (41,08%; n=76 e 43,2%; n=80, respectivamente). Na mortalidade pós-neonatal, 57,3% (n=106) apresentaram tendências decrescentes. Conclusões: houve tendência temporal de declínio da mortalidade infantil geral, embora haja importante parcela de municípios com tendência estacionária, justificando a necessidade de reduzir desigualdades sociais e assimetrias geográficas.

A pandemia de covid-19 e a morbidade hospitalar por transtorno mental e comportamental no Brasil: uma análise de série temporal interrompida, janeiro de 2008 a julho de 2021 / La pandemia de covid-19 y la morbilidad hospitalaria por trastornos mentales y del comportamiento en Brasil: un análisis de series temporales interrompidas, de enero de 2008 a julio de 2021 / The covid-19 pandemic and hospital morbidity due to mental and behavioral disorders in Brazil: an interrupted time series analysis, from January 2008 to July 2021

Objective: to analyze records of hospitalizations due to mental and behavioral disorders before and after the beginning of the covid-19 pandemic in Brazil, from January 2008 to July 2021. Methods: this was a descriptive ecological interrupted time series study, using secondary data retrieved from the Brazilian National Health System Hospital Information System; a time series analysis of hospitalizations was conducted based on a population-weighted Poisson regression model; relative risk (RR) and respective 95% confidence intervals (95%CI) were calculated. Results: we identified 6,329,088 hospitalizations due to mental and behavioral disorders; hospitalization rates showed an 8% decrease (RR = 0.92; 95%CI 0.91;0.92) after the start of the pandemic, compared to the pre-pandemic period. Conclusion: the pandemic changed the trend of hospitalizations due to mental and behavioral disorders in Brazil; the drop observed in the period is evidence that the pandemic affected the mental health care network.

Objetivo: analizar las hospitalizaciones por trastornos mentales y del comportamiento antes y después del inicio de la pandemia de covid-19 en Brasil, desde enero 2008 hasta julio 2021. Método: estudio ecológico descriptivo de series temporales interrumpidas, con datos registrados en el Sistema de Informações Hospitalares del Sistema Único de Saúde; se realizó un análisis de series temporales de hospitalizaciones basado en modelo de regresión de Poisson, ponderado por la población; calculado el riesgo relativo (RR), con intervalo de confianza del (IC95%). Resultados: se identificaron 6.329.088 hospitalizaciones por trastornos mentales y del comportamiento; las tasas de hospitalización mostraron disminución del 8% (RR = 0,92; IC95% 0,91;0,92) tras el inicio de la pandemia, en relación con el periodo prepandémico. Conclusión: la pandemia cambió la tendencia de hospitalizaciones por trastornos mentales y del comportamiento en Brasil; la caída observada en el período evidencia que la pandemia afectó la cadena asistencial estructurada para la salud mental.

Objetivo: analisar as internações por transtorno mental e comportamental, antes e após o início da pandemia de covid-19 no Brasil, de janeiro de 2008 a julho de 2021. Métodos: estudo ecológico descritivo de série temporal interrompida, com dados registrados no Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH/SUS); realizada análise da série temporal das internações baseada em um modelo de regressão de Poisson, ponderado pela população; calculado o risco relativo (RR), com intervalo de confiança de 95% (IC95%). Resultados: foram identificadas 6.329.088 internações por transtornos mentais e comportamentais; as taxas de internação apresentaram um decréscimo de 8% (RR = 0,92; IC95% 0,91;0,92) após o início da pandemia, em relação ao período pré-pandemia. Conclusão: a pandemia modificou a tendência das internações por transtornos mentais e comportamentais no Brasil; a queda observada no período é evidência de que a pandemia afetou a cadeia de cuidado estruturada para saúde mental.

Bilateral continuous erector spinae plane block for cardiac surgery: case series / Bloqueo bilateral continúo del plano erector de la espina para cirugía cardiaca: serie de casos

Abstract Multimodal analgesia in cardiac surgery sternotomy includes bilateral continuous erector spinae plane block (BC-ESPB). However, the effectiveness of the local anesthetic regimens is still uncertain. The purpose of this study was to assess pain control achieved with a multimodal analgesia regimen including BC-ESPB at the level of T5 with PCA with a 0.125 % bupivacaine infusion and rescue boluses. This is a descriptive case series study which recruited 11 adult patients undergoing cardiac surgery through sternotomy in whom multimodal analgesia including BC-ESPB was used, between February and April 2021, at a fourth level institution. All patients reported pain according to the numeric rating scale (NRS) ≤ 3 both at rest and in motion, at extubation and then 4 and 12 hours after surgery. After 24 hours the pain was NRS ≤ 3 in 100 % of the patients at rest and in 63.6 % in motion. At 48 h 81 % of the patients reported pain NRS ≤ 3 at rest and in motion. At 72h all patients reported pain NRS ≤ 3 at rest and 82 % in motion. The average intraoperative use of fentanyl was 2.35 µg/kg and postoperative hydromorphone was 5.3, 4.1 and 3.3 mg at 24, 48 and 72 hours, respectively. Hence, bilateral ESP block in continuous infusion plus rescue boluses allows for proper control of acute intra and post-operative pain.

Resumen En cirugía cardiaca mediante esternotomía, la analgesia multimodal incluye el bloqueo bilateral continuo del plano erector de la espina (BBC-ESP). Sin embargo, existe incertidumbre sobre la efectividad de los esquemas de dosificación del anestésico local. Se busca evaluar el control del dolor proporcionado por un esquema de analgesia multimodal que incluye el BBC-ESP a la altura de T5 con ACP de bupivacaína 0,125 % en infusión y bolos de rescate. Se trata de un estudio descriptivo, serie de casos. Se reclutaron 11 pacientes adultos sometidos a cirugía cardiaca mediante esternotomía en quienes se usó analgesia multimodal que incluía BBC-ESP entre febrero y abril del 2021, en una institución de cuarto nivel. Todos los pacientes refirieron dolor, según la escala numérica (EN) ≤ 3 tanto en reposo como en movimiento, a la extubación, a las 4 y a las 12 horas. A las 24 horas el dolor fue EN ≤ 3 en el 100 % de los pacientes en reposo y en el 63,6 % en movimiento. A las 48 h el 81 % de los pacientes refirieron dolor EN ≤ 3 en reposo y en movimiento. A las 72 h todos los pacientes presentaron dolor EN ≤ 3 en reposo y 82 % en movimiento. El consumo intraoperatorio promedio de fentanilo fue de 2,35 ug/kg y de hidromorfona posoperatoria de 5,3, 4,1 y 3,3 mg a las 24, 48 y 72 horas. Así, el BBC-ESP en infusión continua más bolos de rescate permiten el control del dolor agudo intra y posoperatorio.

Relaciones directas e indirectas entre apoyo familiar, comidas familiares, satisfacción familiar y vital en trabajadores / Direct and indirect relations between family support, family meals, family and life satisfaction in workers

Resumen Introducción: Para las personas con trabajo remunerado, la familia es una fuente importante de recursos psicológicos que contribuyen a su bienestar. Se hipotetiza que el apoyo familiar es un factor protector de la satisfacción vital de la persona, de modo directo y a través de otras variables como las comidas familiares y la satisfacción con la vida familiar. En ese sentido, el objetivo de este estudio fue examinar el papel mediador en serie de la atmósfera de las comidas familiares y la satisfacción con la vida familiar en la relación entre el apoyo familiar y la satisfacción con la vida, en mujeres y hombres con trabajos remunerados. Método: Se aplicó la Escala de Satisfacción con la Vida, Escala Multidimensional de Apoyo Social Percibido, Escala Atmósfera de las Comidas Familiares y Escala de Satisfacción con la Vida Familiar, a una muestra de 236 mujeres y 236 hombres con trabajo remunerado en Temuco, Chile. El análisis estadístico consideró un modelo de mediación en serie con un Intervalo de Confianza del 95%. Resultados: El apoyo familiar y la satisfacción con la vida correlacionaron de forma directa y estadísticamente significativa. Además, se obtuvo un efecto indirecto significativo de la atmósfera de las comidas familiares y la satisfacción con la vida familiar, en la relación entre el apoyo familiar y la satisfacción con la vida. La atmósfera de las comidas familiares y la satisfacción con la vida familiar son mediadores en serie en la relación entre el apoyo familiar y la satisfacción con la vida, en este grupo de trabajadores. Conclusiones: Los resultados sugieren que variables asociadas a la familia y a aspectos sociales de la alimentación influyen positivamente en la satisfacción vital de los trabajadores.

Abstract Introduction: For workers, family is an important source of psychological resources that contribute to the individual's well-being. It is hypothesized that family support is a protective factor of the person's life satisfaction, directly and through other variables such as family meals and satisfaction with family life. In this regard, the aim of this study was to examine the serial mediating role of the atmosphere of family meals and satisfaction with family life in the relationship between family support and satisfaction with life, in women and men with paid jobs. Method: The Satisfaction with Life Scale, the Multidimensional Scale of Perceived Social Support (family subscale), a measure of Atmosphere Scale of Family Meals and the Satisfaction with Family Life Scale were administered to a sample of 236 women and 236 men with paid jobs in Temuco, Chile. The statistical analysis considered a serial mediation model with a 95% Confidence Interval. Results: Family support and satisfaction with life significantly correlated with one another. In addition, a significant indirect effect of the atmosphere of family meals and satisfaction with family life was obtained in the relationship between family support and life satisfaction. The atmosphere of family meals and satisfaction with family life are serial mediators in the relationship between family support and life satisfaction in this group of workers. Conclusions: Results suggest that variables related to the family domain and to social aspects of food consumption have a positive impact in workers' life satisfaction.

Prurigo crónico nodular: Estudio retrospectivo de 74 casos / Chronic Nodular Prurigo: A Retrospective Study of 74 Cases

Antecedentes y objetivo El prurigo crónico nodular (PCN) es una enfermedad recientemente definida, de etiología heterogénea e infradiagnosticado en la actualidad. Está asociado a múltiples comorbilidades y los avances en su patogenia han abierto puertas a un mejor manejo y tratamiento. Presentamos una serie de pacientes con PCN con el objetivo de aportar nuestra experiencia en el manejo de esta entidad. Material y métodos Se realizó un estudio observacional, retrospectivo y unicéntrico que incluye pacientes con PCN atendidos en el Servicio de Dermatología de un hospital terciario entre 2009 y 2021. Se recogieron variables sociodemográficas y clínicas. Resultados Se incluyó 74 pacientes, mayoritariamente mujeres (63,5%), con una media de 57 años. La asociación del PCN con otras enfermedades cutáneas fue del 39,2%, sobre todo dermatitis atópica (62%). El 54,1% de los pacientes presentaron comorbilidad endocrina y el 44,4% comorbilidad cardiovascular. La asociación con enfermedad psiquiátrica fue del 36,5%. La biopsia cutánea fue útil para confirmar la sospecha clínica en el 70% de los casos. El valor medio de la IgE fue superior a la normalidad (516 UI/mL), independientemente de la existencia de predisposición atópica. Se utilizó una media de tres tratamientos para el PCN por paciente. El metotrexato, los antihistamínicos y los corticoides tópicos y orales fueron los más empleados, estando el primero entre los más eficaces. Conclusione El PCN es una enfermedad compleja asociada a un gran número de comorbilidades, que requiere una aproximación multidisciplinar con el dermatólogo como eje central. El manejo terapéutico clásico es probablemente inadecuado (AU)

Background and objective Chronic nodular prurigo (CNPG) is a recently defined and currently underdiagnosed disease with a variety of causes. It is associated with multiple comorbidities, and its management and treatment have improved with a better understanding of its pathogenesis. The aim of this study was to describe our experience with a series of patients with CNPG. Material and methods Single-center, observational, retrospective study of the sociodemographic and clinical characteristics of patients with CNPG seen at the dermatology department of a tertiary care hospital between 2009 and 2021. Results We included 74 patients, mostly women (63.5%), with a mean age of 57 years. Overall, 39.2% of patients had a concomitant skin condition, mainly atopic dermatitis (62%). Other comorbidities included endocrine disorders (54.1%), cardiovascular disease (44.4%), and psychiatric disorders (36.5%). Skin biopsy helped confirm the clinical diagnosis in 70% of cases. The mean immunoglobulin E level was higher than normal (516 IU/mL), regardless of atopic predisposition. On average, patients received 3 treatments, the most common choices being methotrexate, antihistamines, and topical and oral corticosteroids. Methotrexate was among the most effective options. Conclusions CNPG is a complex disease associated with multiple comorbidities. It requires a multidisciplinary approach, with the dermatologist at the center. Classical treatment approaches are probably insufficient (AU)

[Translated article] Chronic Nodular Prurigo: A Retrospective Study of 74 Cases / Prurigo crónico nodular: estudio retrospectivo de 74 casos

Background and objective Chronic nodular prurigo (CNPG) is a recently defined and currently underdiagnosed disease with a variety of causes. It is associated with multiple comorbidities, and its management and treatment have improved with a better understanding of its pathogenesis. The aim of this study was to describe our experience with a series of patients with CNPG. Material and methods Single-center, observational, retrospective study of the sociodemographic and clinical characteristics of patients with CNPG seen at the dermatology department of a tertiary care hospital between 2009 and 2021. Results We included 74 patients, mostly women (63.5%), with a mean age of 57 years. Overall, 39.2% of patients had a concomitant skin condition, mainly atopic dermatitis (62%). Other comorbidities included endocrine disorders (54.1%), cardiovascular disease (44.4%), and psychiatric disorders (36.5%). Skin biopsy helped confirm the clinical diagnosis in 70% of cases. The mean immunoglobulin E level was higher than normal (516 IU/mL), regardless of atopic predisposition. On average, patients received 3 treatments, the most common choices being methotrexate, antihistamines, and topical and oral corticosteroids. Methotrexate was among the most effective options. Conclusions CNPG is a complex disease associated with multiple comorbidities. It requires a multidisciplinary approach, with the dermatologist at the center. Classical treatment approaches are probably insufficient (AU)

Antecedentes y objetivo El prurigo crónico nodular (PCN) es una enfermedad recientemente definida, de etiología heterogénea e infradiagnosticado en la actualidad. Está asociado a múltiples comorbilidades y los avances en su patogenia han abierto puertas a un mejor manejo y tratamiento. Presentamos una serie de pacientes con PCN con el objetivo de aportar nuestra experiencia en el manejo de esta entidad. Material y métodos Se realizó un estudio observacional, retrospectivo y unicéntrico que incluye pacientes con PCN atendidos en el Servicio de Dermatología de un hospital terciario entre 2009 y 2021. Se recogieron variables sociodemográficas y clínicas. Resultados Se incluyó 74 pacientes, mayoritariamente mujeres (63,5%), con una media de 57 años. La asociación del PCN con otras enfermedades cutáneas fue del 39,2%, sobre todo dermatitis atópica (62%). El 54,1% de los pacientes presentaron comorbilidad endocrina y el 44,4% comorbilidad cardiovascular. La asociación con enfermedad psiquiátrica fue del 36,5%. La biopsia cutánea fue útil para confirmar la sospecha clínica en el 70% de los casos. El valor medio de la IgE fue superior a la normalidad (516 UI/mL), independientemente de la existencia de predisposición atópica. Se utilizó una media de tres tratamientos para el PCN por paciente. El metotrexato, los antihistamínicos y los corticoides tópicos y orales fueron los más empleados, estando el primero entre los más eficaces. Conclusiones El PCN es una enfermedad compleja asociada a un gran número de comorbilidades, que requiere una aproximación multidisciplinar con el dermatólogo como eje central. El manejo terapéutico clásico es probablemente inadecuado (AU)