Abstract The emergence of toothpastes containing different abrasive and whitening substances has been a constant concern among dental professionals. The aim of the present study was to perform an in vitro assessment of the surface topography of nanoparticle composite resins subjected to simulated brushing with dentifrices. Test samples were prepared with Filtek Universal (3M ESPE), Filtek Bulkfill (3M ESPE) and Z350 (3M ESPE), with 24 samples per resin. A testing machine was used to simulate brushing with the dentifrices Colgate Total 12, Oral B 100% and Oral B Gengiva Detox Gentle Whitening (8 samples per group). The constant speed of the machine was 250 cycles per minute, and 20.000 cycles were carried out, which corresponds to 24 months (1 hour and 20 minutes). Roughness features and qualitative surface topography were investigated. Statistical analysis involved the Kruskal–Wallis, Wilcoxon and Mann–Whitney tests. A significant increase in surface roughness was found for all the resins (p < 0.05). However, no significant difference was found among the resins in terms of final roughness values (p = 0.690). In contrast, a significant difference among dentifrices was found with respect to roughness measurements (p < 0.001). The qualitative analysis revealed an increase in surface roughness in all the samples and differences in the abrasive potential of the dentifrices. In conclusion, brushing with dentifrices increases the surface roughness parameters of composite resin restorations. Moreover, the differences in the abrasive effects of the dentifrices indicate a need for further studies to establish efficacy and safety criteria.

ABSTRACT Immune thrombocytopenia (ITP) is an autoimmune hematological condition characterized by a markedly isolated decrease in platelets without any apparent associated clinical conditions, resulting in bleeding and bruising of the skin, mucous membranes, and major organs. It is often triggered by preceding illness or several immune stimulants such as immunizations, infections, allergic reactions, among others. While uncommon, arthropod bites can trigger acute ITP. Four cases have been reported due to bee stings and insect bites, as well as a case of ITP following honeybee-venom therapy. Here, we report a case of acute ITP possibly triggered by multiple tick bites.

Abstract Specific Pathogen-Free (SPF) animals are bred and maintained to exclude pathogens associated with significant morbidity or mortality, which may pose a risk to research replicability. The BALB/c strain is distributed globally and is among the most commonly used inbred strains in immunology and infectious disease research. Despite being a widely distributed bacterium that causes chronic infection, Bartonella henselae infection has not been investigated in any protocol that characterizes SPF animals. The objective of this study was to investigate the potential natural infection of laboratory animals of the BALB/c lineage by B. henselae. To achieve this, ten immunocompetent BALB/c mice were obtained directly from the bioterium and euthanized for collection of samples, including blood, skin, spleen, liver, heart, eye, kidney, intestine, esophagus, and brain. DNA was extracted using a commercial kit and tested via nested PCR for the ftsZ gene, as well as conventional PCR and qualitative real-time PCR using Sybr® Green for the citrate synthase gene (gltA), all specific reactions for B. henselae. All animals showed detection of B. henselae DNA in at least two different reactions in different tissues. The sequenced amplicons showed 100 % similarity to B. henselae. The use of mice infected by B. henselae in experiments is undesirable, as the bacteria can affect several aspects of the animal's physiology and consequently influence the results of the project, especially when subjected to immunosuppression. More studies are needed to understand and confirm the natural infection in experimental animals by Bartonella spp.. To date, no additional published reports of contamination of experimental animals by these bacteria have been identified.

BACKGROUND The nematode Angiostrongylus cantonensis, which is endemic to Southeast Asia and adjacent Pacific Islands, has already been recorded in more than 30 countries, including Brazil and other South American nations. It is one of the principal etiological agents of the zoonosis Eosinophilic Meningitis (EoM), which has a number of different species of terrestrial gastropods that act as its intermediate hosts. OBJECTIVE The present study investigated the occurrence of the larvae of this nematode in specimens of terrestrial molluscs collected in half of the municipalities of the Brazilian State of Rio de Janeiro. METHODS The study is based on the surveillance of this nematode in the Brazilian State of Rio de Janeiro, where terrestrial snails and slugs were collected in more than half of the state’s municipalities (46 in all), and examined for parasitological infections. The nematode larvae retrieved from these specimens were identified based on their morphology and cytochrome oxidase I (COI) mitochondrial DNA sequences. FINDINGS Angiostrongylid larvae were found in 230 (8.8%) of the 2,600 terrestrial molluscs examined, collected from 26 municipalities. Overall, 14 terrestrial gastropod species were identified, including both native and exotic taxa, and six were found to be infected naturally by A. cantonensis. The natural infection rates by Angiostrongylus in the different terrestrial molluscs species were 12.5% in Angustipes erinaceus, 9.7% in Achatina fulica, 6.8% in Bradybaena similaris, 6.3% in Sarasinula linguaeformis, 3.9% in Leptinaria unilamellata, and 4.6% in Subulina octona. A. fulica was the most frequent and extensively distributed species, with infected snails being found in 22 municipalities. MAIN CONCLUSIONS The data from this first comprehensive survey of A. cantonensis in Rio de Janeiro highlights the potential epidemiological risk of human infection in this state. Mapping the spread of infected molluscs will also provide essential information for the evaluation of the risk of human infection, and should help local health authorities to provide a faster and more accurate diagnosis whenever neuroangiostrongyliasis is suspected.

RESUMO Objetivo: A última edição do Levantamento de Cenas de Uso de Capitais (LECUCA) investigou indicadores de vulnerabilidade social, de saúde e uso de serviços de saúde e assistência entre frequentadores das cenas abertas de uso (CAU) de crack em São Paulo, Fortaleza e Brasília entre 2021/2022. Métodos: Desde 2016, o LECUCA utiliza a amostragem por Tempo-Localização (TLS) para selecionar amostras probabilísticas representativas da população de frequentadores da CAU. Resultados: Foram entrevistados 579 participantes em São Paulo, Fortaleza e Brasília, com índice de resposta de 75%. Os frequentadores das CAUs não se diferenciam nas prevalências de indicadores sociodemográficos e tempo na cena. As prevalências de frequentadores que nunca estiveram em situação de rua antes de viver na CAU e provenientes de casa foram igualmente altas nas três capitais. Fortaleza se destaca com menores índices de situação de rua e de acesso a equipamentos de saúde especializados, enquanto Brasília apresenta índices elevados de busca por emergência devido ao consumo de drogas e maior acesso a todas as modalidades de serviço de saúde e assistência. Mais de um terço dos frequentadores das CAUs pratica sexo desprotegido e nenhuma das capitais teve mais da metade dos frequentadores testados para Tuberculose e Infecções Sexualmente Transmissíveis (ISTs). Os índices de problemas na gestação foram altos entre todas as capitais, com os menores índices em São Paulo. Conclusão: O LECUCA oferece subsídios importantes para gestores governamentais e institucionais, com o intuito de catalisar o desenvolvimento de políticas públicas e estratégias de atendimento fundamentadas em dados e evidências.

ABSTRACT Objective: The latest edition of the Open Drug Scenes Survey in Brazilian Cities (LECUCA) investigated social vulnerability, health, and the use of the Psychosocial Care Network by attendees of open drug scenes (ODSs) involving crack cocaine in São Paulo, Fortaleza, and Brasília between 2021/2022. Methods: Since 2016, LECUCA has used Time-Location Sampling (TLS) to select probabilistic samples representative of the population of ODS attendees. Results: We interviewed 579 participants in São Paulo, Fortaleza, and Brasília, obtaining a response rate of 75%. We found no difference in ODS attendees regarding the prevalence of sociodemographic indicators and time living in the ODS. The prevalence values of attendees who had never been homeless before living in the ODS and those living in their homes were equally high in the three capitals. Fortaleza stood out for having lower rates of homelessness and limited access to specialized health services, whereas Brasília had high rates of searching for emergency services due to drug use and greater access to all modalities of health and assistance services. Unprotected sex was prevalent over one third of ODSs attendees, and none of the capitals had more than half of the attendees testing for tuberculosis and sexually transmitted infections. Rates of pregnancy complications were high in all three capitals, with São Paulo accounting for the lowest rates. Conclusion: LECUCA provides significant subsidies to governmental and institutional managers, aiming at catalyzing the formulation of public policies and care strategies based on data and evidence.

RESUMEN Se realizó una revisión sistemática de publicaciones brasileñas sobre el deber psicológico entre 2010-2021. Trinta y cinco estudios fueron analizados a partir de las categorías: base de datos; año; periódico; autores; afiliación; tipo de estudio; fundamento teórico; tema y contexto de la acción. Los resultados indican: irregularidad temporal en las producciones; predominio de publicaciones en dos revistas; prevalencia de artículos realizados en parejas; producciones mayoritarias de autores con incursiones puntuales; hegemonía de textos vinculados a instituciones públicas; mayoría de afiliaciones en la región Sudeste; informes de experiencia y producciones teóricas como las más recurrentes; ECP y la Fenomenología Existencial como fundamentos más incidentes; concentración de temas relacionados con la universidad. Se concluye que esta revisión describe una visión general actual del cambio.

RESUMO Realizou-se uma revisão sistemática das publicações brasileiras sobre o plantão psicológico, entre 2010-2021. Trinta e cinco estudos foram analisados a partir das categorias: base de dados; ano; periódico; autores; filiação; tipo de estudo; fundamento teórico; tema e contexto de atuação. Os resultados indicam: irregularidade temporal nas produções; predominância de publicações em dois periódicos; prevalência de artigos realizados em duplas; maioria de produções advindas de autores com incursões pontuais; hegemonia de textos vinculados à instituições públicas; maioria de filiações na região Sudeste; relatos de experiência e produções teóricas como mais recorrentes; ACP e Fenomenologia-Existencial como fundamentações mais incidentes; concentração de temas relacionados à universidade. Conclui-se que esta revisão descreve um panorama geral-atual sobre o plantão.

ABSTRACT A systematic review of brazilian publications on psychological duty was carried out between 20102021. Thirty-five essays were analyzed from the categories: database; year; periodical; authors; affiliation; kind of study; theoretical foundation; theme and context of action. The results indicate: temporal irregularity in the writings; publications predominance in two journals; articles’ prevalence performed in pairs; most writings come from authors with occasional incursions; texts’ hegemony linked to public institutions; affiliations’ majority in the Southeast region; experience reports and theoretical writings as the most recurrent; PCA and Existential-Phenomenology as more incident foundations; concentration of themes university related. It is concluded that this review describes a psychological duty current overview.

Resumo Este estudo faz uma revisão exaustiva da literatura desde 2000 abordando a investigação contemporânea em turismo e hotelaria. A pesquisa realizou análise bibliométrica e modelação de temas com recurso ao software R abrangendo mais de 18 mil artigos publicados nas principais revistas (primeiro decil) de acordo com o ranking Scopus. A nossa investigação determina a estrutura de conhecimento da investigação em turismo e hotelaria e identifica as tendências atuais de investigação através da intersecção de temas co-ocorrentes e modelação de tópicos. O impacto dos desenvolvimentos tecnológicos, a importância da sustentabilidade nas práticas turísticas e a investigação do comportamento dos visitantes e dos processos de tomada de decisão estão entre os pontos focais. Além disso, o nosso estudo propõe orientações para futuras pesquisas através da identificação de uma série de caminhos interessantes para futuras investigações que irão colmatar carências urgentes na área. Estas incluem tornar o turismo mais inclusivo e acessível, fazer uso de tecnologias de ponta e utilizar a diplomacia cultural para melhorar a sustentabilidade do turismo.

Abstract This study comprehensively reviews the literature since 2000 addressing contemporary tourism and hospitality research. The research conducted bibliometric analysis and topic modeling using R software encompassing over 18 thousand articles published in the top journals (first decile) according to the Scopus rankings. Our investigation determines the knowledge structure of research on tourism and hospitality and identifies current research trends through the intersection of the co-occurring themes and topic modeling topics. The impact of technological developments, the significance of sustainability in tourism practices, and the investigation of visitor behavior and decision-making processes are among the focal points. Furthermore, our study proposes directions for future research through the identification of a number of interesting avenues for further investigation that will fill in urgent shortages in the area. They include making tourism more inclusive and accessible, making use of cutting-edge technologies, and utilizing cultural diplomacy to improve the sustainability of tourism.

Resumo Objetivo: Reportar a experiência de um centro no tratamento de paragangliomas do osso temporal com radiocirurgia robótica. Desenho do Estudo: Análise retrospetiva unicêntrica Material e Métodos: Entre 2017 e 2021, 8 doentes com paragangliomas do osso temporal receberam tratamento com Cyberknife no Serviço de Radioterapia do Instituto CUF Porto. Resultados: Metade dos doentes apresentavam recidiva tumoral após cirurgia +/- embolização. O tempo de seguimento médio foi de 33 meses. Relativamente à resposta clínica, 4 doentes melhoraram dos sintomas pré-radiocirurgia, 2 mantiveram-se assintomáticos e 2 apresentaram estabilidade neurológica. Todos os tumores revelaram regressão (n=5) ou estabilidade dimensional (n=3) - seguimento com ressonância magnética (RM), com um controlo local de 100%. Não foi reportada toxicidade aguda grau ≥3 ou tardia. Conclusões: Na presente análise, a radiocirurgia robótica parece demonstrar ser uma abordagem terapêutica útil na gestão dos paragangliomas do osso temporal, quer nas recidivas após cirurgia e/ou embolização, quer como tratamento radical único.

Abstract Objective: To report the experience of a single center in the treatment of temporal bone paragangliomas with Robotic Radiosurgery. Study Design: Single-center retrospective analysis Material and Methods: Between 2017 and 2021, 8 patients with temporal bone paragangliomas were treated with Cyberknife in the Department of Radiation Oncology of Instituto CUF Porto. Results: Half of the patients were diagnosed with recurrent tumors after surgery +/- embolization. The median follow-up was 33 months. Regarding clinical outcomes, 4 patients showed improvement in pre-radiosurgery symptoms, 2 remained symptom-free and 2 demonstrated neurological stability. All tumors revealed regression (n=5) or stable dimension (n=3) during follow-up MRI, with local control of 100%. There was no grade ≥3 or late toxicities. Conclusion: Robotic Radiosurgery seems to be a helpful therapeutic approach in the management of temporal bone paragangliomas, either after surgery and/or embolization recurrences or as a single and radical treatment.

Abstract The Anais Brasileiros de Dermatologia, published since 1925, is the most influential dermatological journal in Latin America, indexed in the main international bibliographic databases, and occupies the 50th position among the 70 dermatological journals indexed in the Journal of Citations Reports, in 2022. In this article, the authors present a critical analysis of its trajectory in the last decade and compare its main bibliometric indices with Brazilian medical and international dermatological journals. The journal showed consistent growth in different bibliometric indices, which indicates a successful editorial policy and greater visibility in the international scientific community, attracting foreign authors. The increases in citations received (4.1 ×) and in the Article Influence Score (2.9×) were more prominent than those of the main Brazilian medical and international dermatological journals. The success of Anais Brasileiros de Dermatologia in the international scientific scenario depends on an assertive editorial policy, on promptly publication of high-quality articles, and on institutional stimulus to encourage clinical research in dermatology. 1925 America databases th 7 Reports 2022 article community 4.1 41 4 1 (4. × 2.9× 29 2 9 (2.9× highquality high quality articles dermatology 192 202 4. (4 2.9 (2.9 19 20 ( 2. (2. (2

ABSTRACT: The road system is the main mode used for the transportation of agricultural cargo, and in some cases, it is the only option for handling this type of product. This dependence means that the implementation of tools to support the management of logistical costs can reduce the financial impact with the transport felt by the economic agents operating in the soybean chain. This study contributed to a better understanding of the variables that make up the cost of road freight, generating a system of road freight prediction from a multiple linear regression model using the selection of variables Stepwise, Forward, and Backward elimination. This being said, this research intends to evaluate whether the behavior of soybean road freight is influenced by the variables that make up the productive, economic, and infrastructure dimensions in price formation. The regression models had an explanatory power of 87.20%. In the infrastructure dimension, the most impact variable in soybean road freight was the distance traveled; in the economic dimension, the variables of inflation and fuel price stood out; while in the productive dimension, the main contribution was the volume of production. A more assertive predictability of logistical costs and better understanding of the dynamics of freight price formation helps industry agents in planning and decision-making. Another contribution of this study is that it can be used as a practical tool for predicting soybean road freight on several transportation routes.

RESUMO: O sistema rodoviário é o principal modal utilizado para o transporte de cargas agrícolas, e em alguns casos, é a única opção para movimentação desse tipo de produto. Esta dependência faz com que a implementação de ferramentas para apoiar a gestão dos custos logísticos possa reduzir o impacto financeiro com o transporte sentido pelos agentes econômicos que atuam na cadeia da soja. O presente trabalho visa contribuir para um melhor entendimento das variáveis que compõem o custo dos fretes rodoviários, gerando um sistema de previsão de fretes rodoviários a partir de um modelo de regressão linear múltipla usando a seleção de variáveis Stepwise, Forward e a eliminação Backward. Isto posto, a pesquisa tem por objetivo avaliar se o comportamento do frete rodoviário da soja é influenciado pelas variáveis que compõem as dimensões produtivas, econômicas e de infraestrutura na formação do preço. Os modelos de regressão tiveram um poder explicativo de 87,20%. Na dimensão infraestrutura o destaque foi a variável distância percorrida como a mais impactante no frete rodoviário da soja, na dimensão econômica as variáveis inflação e preço do combustível, enquanto que na dimensão produtiva a principal contribuição foi o volume de produção. A previsibilidade mais assertiva dos custos logísticos e melhor compreensão da dinâmica de formação do preço do frete auxilia os agentes do setor no planejamento e na tomada de decisão. Outra contribuição deste trabalho é que pode ser usado como uma ferramenta prática para a predição de fretes rodoviários da soja em diversas rotas de transporte.

ABSTRACT BACKGROUND: Down syndrome (DS) is a non-rare genetic condition that affects approximately 1 in every 800 live births worldwide. Further, it is associated with comorbidities, anatomical alterations of the respiratory tract, and immunological dysfunctions that make individuals more susceptible to respiratory infections. OBJECTIVE: To systematize the current scientific knowledge about the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among individuals with DS. DESIGN AND SETTING: This integrative review was conducted at the Universidade Federal de São Carlos, São Paulo, Brazil. METHODS: This review was conducted in the following databases: the Virtual Health Library (Biblioteca Virtual em Saúde, BVS), PubMed, and Web of Science, using MeSH descriptors. The search included English or Portuguese studies published between January 1, 2020, and October 14, 2022. RESULTS: A total of 55 articles from 24 countries were selected, comprising 21 case-control or cohort studies, 23 case reports or series, and 11 narrative reviews or opinion studies. The articles were grouped into five categories: previous comorbidities, coronavirus disease 2019 (COVID-19) clinical features and evolution, cytokine storm and interleukins, living in institutions as a risk factor, and behavioral actions as a protective factor against SARS-CoV-2 infection. CONCLUSION: Individuals with DS are more susceptible to COVID-19 infection due to variables such as previous comorbidities, immunological factors, and their habitable environments. These aspects confer a higher risk of infection and an unfavorable clinical course. The precise pathways involved in the pathophysiology of COVID-19 in individuals with DS are not clear, thus requiring further studies. SYSTEMATIC REVIEW REGISTRATION: The Open Science Framework registered the research protocol (https://osf.io/jyb97/).

Resumo Objetivo: Comparar uso e preenchimento da caderneta da criança entre mães beneficiárias ou não do Programa Bolsa Família. Métodos: Estudo transversal com mães de crianças menores de 6 anos em unidades de saúde de Salvador-BA, entre janeiro e fevereiro de 2023. A caderneta da criança foi avaliada quanto ao uso (ter a caderneta, estar com ela em mãos e tê-la lido) e preenchimento (curvas de crescimento, fichas de avaliação do desenvolvimento e completude vacinal). Utilizaram-se estatística descritiva e teste qui-quadrado, com nível de significância de 5%. Resultados: Das 411 participantes do estudo, 66% eram beneficiárias do programa. Houve diferença significativa entre os grupos quanto ao uso da caderneta: ter a caderneta (p < 0,001), estar com ela em mãos (p = 0,037) e tê-la lido (p < 0,001). Quanto ao preenchimento, houve diferença significativa apenas na completude vacinal (p = 0,005). Conclusão: Houve diferença significativa quanto ao uso e à completude vacinal, comparando-se mães beneficiárias e não beneficiárias do Programa Bolsa Família.

Resumen Objetivo: Comparar uso y registro del carné de control pediátrico (CCP) entre madres beneficiarias y no beneficiarias del Programa Bolsa Familia (PBF). Métodos: Estudio transversal entre enero y febrero del 2023 con madres de niños < 6años, en unidades de salud de Salvador-Bahía. Se evaluó CSN en términos de uso (tener el carné, tenerlo en mano y haberlo leído) y registro (curvas de crecimiento, formularios del desarrollo y vacunación). Se utilizó estadística descriptiva y prueba de chi-cuadrado. Resultados: De los 411 participantes, el 66% fueron del PBF. Hubo diferencia significativa entre los grupos respecto al uso del CCP: tenerlo (p < 0,001), concurrir con él (p = 0,037) haberlo leído (p < 0,001). Respecto al registro, hubo diferencia significativa sólo en vacunación (p = 0,005). Conclusión: Hubo diferencia significativa en el uso y cumplimiento de la vacunación, comparando madres beneficiarias y no beneficiarias del PBF.

Abstract Objective: To compare child health booklet (CHB) use and filling out among mothers who were or were not Bolsa Família Program (BFP) beneficiaries. Methods: Cross-sectional study with mothers of children <6years attending health centers in Salvador, Bahia, Brazil, between January-February/2023. The CHB was evaluated regarding its use (having a CHB, having it in hand, and having read it) and filling out (growth curves, development monitoring forms, and vaccination completeness). Descriptive statistics and the chi-square test were used. Results: Of the 411 study participants, 66% were BFP beneficiaries. Significant differences were found between the groups regarding CHB use: having a CHB (p < 0.001), having it in hand (p = 0.037), and having read it (p < 0.001). Significant difference in vaccination completeness was found (p = 0.005). Conclusion: There was a significant difference in CHB use and vaccination completeness when comparing mothers who were BFP beneficiaries and those who were not.

RESUMO Objetivo Descrever os acidentes por picada de aranhas-marrons (gênero Loxosceles), notificados no Centro de Informação de Assistência Toxicológica de Pernambuco (CIATox-PE), Brasil, no período de 2018 a 2022. Métodos Estudo de série, sobre casos notificados no CIATox-PE. Resultados Foram incluídos 22 casos com mediana de idade de 35 anos e houve predomínio do sexo feminino (13); os casos ocorreram nas zonas rural e urbana (12 versus 10), durante a noite (10), e Petrolina foi o município com mais notificações (6); as picadas ocorreram, principalmente, nos membros inferiores (11) e superiores (9), quase exclusivamente dentro das residências (21); para 8 acidentados, não se prescreveu soroterapia específica por terem ultrapassado o tempo de efetividade. Conclusão Os casos de loxoscelismo ocorreram com maior frequência no sexo feminino, nas zonas rural e urbana indiferentemente, quase todos foram intradomiciliares e houve demora na procura por atendimento médico.

RESUMEN Objetivo Describir accidentes causados por arañas pardas (género Loxosceles) notificados por el Centro de Información de Asistencia Toxicológica de Pernambuco (CIATox-PE), Brasil, de enero de 2018 a diciembre de 2022. Métodos Reporte de 22 casos notificados de CIATox-PE. Resultados Casos con media de idade de 35 años, predominio femenino (13); los casos ocurrieron en área rural/urbana (12 versus 10), por la noche (10); Petrolina fue el municipio con más notificaciones (6); las picaduras fueron principalmente en los miembros inferiores (11) y superiores (9), casi exclusivamente en el interior de las viviendas (21); en 8 de los casos no se indicó sueroterapia específica por haber superado el tiempo de efecto. Conclusión Los casos de loxoscelismo ocurrieron con mayor frecuencia en el sexo femenino, en áreas rurales y urbanas, y principalmente en el hogar, con demoras en la búsqueda de atención médica.

ABSTRACT Objective To describe accidents involving brown spider (genus Loxosceles) bites notified by the Pernambuco Poison Information and Care Center (CIATox-PE), Brazil, from January 2018 to December 2022. Methods This was a case series study of brown spider bites notified by the CIATox-PE. Results The study included 22 cases with median age of 35 years, the majority being female (13); the cases occurred in rural and urban areas (12 versus 10), at night (10); Petrolina was the municipality with the highest number of notifications (6); spider bites occurred mainly in the lower (11) and upper (9) limbs, almost exclusively inside households (21); specific serum therapy was not indicated for 8 cases because the time for its effectiveness had already elapsed. Conclusion Loxoscelism cases occurred more frequently in females, in both rural and urban areas and mainly at home, with delays in seeking medical care.