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This conceptual article provides a description of trauma-informed educational practices informed by a model of trauma-informed educational practice (TIEP) that was created for social work education. We subsequently will call for an integration of this model to counselor education. To demonstrate an application of the model into counselor education, we will provide a case study influenced by both the TIEP model and our experiences in working in a CACREP-accredited counselor education program that infuses trauma content throughout its program curriculum. [ABSTRACT FROM AUTHOR]

Acute Myeloid Leukemia (AML), a malignant neoplasm characterized by the rapid proliferation of abnormal cells in the bone marrow, often manifests oral signs such as gingival bleeding and purple-colored gum hyperplasia. This clinical case underscores the pivotal role of dentists in diagnosing AML, shedding light on the nuanced presentation of hematological diseases in the oral cavity. A 57-year-old Caucasian female with a history of fibromyalgia and current use of Fluoxetine and Amitriptyline presented with a chief complaint of gum pain and bleeding persisting for 60 days. Clinical examination revealed distinctive purple hemorrhagic gingival hyperplasia, prompting a comprehensive evaluation. Initial investigations, including a full blood count, clotting profile, and HIV serology (suspected Kaposi's sarcoma), returned within normal parameters. Recognizing the potential severity of the oral manifestation, the patient was promptly referred for oncology-hematology assessment. Given the suspicion of an underlying hematologic condition, an incisional biopsy was performed, revealing a diagnosis of Acute Myeloid Leukemia. This diagnosis, unexpected in the absence of abnormal laboratory findings, underscores the imperative role of dental professionals in early detection and referral. This case serves as a compelling example highlighting the significance of dental professionals in identifying potentially life-threatening oral lesions, even when routine laboratory tests appear normal. The timely and astute recognition of aberrant oral presentations can expedite referral to specialized medical care, significantly influencing patient outcomes. In essence, the presented case reinforces the critical collaboration between dentists and oncology-hematology specialists, emphasizing the need for a comprehensive understanding of oral manifestations of systemic diseases. This interdisciplinary approach contributes not only to the prompt diagnosis of potentially severe conditions like AML but also to the overall well-being of the patient. [ABSTRACT FROM AUTHOR]

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Many patients hospitalized with COVID-19 were unable to return to work or their return was delayed due to their health condition. The aim of this observational study was to evaluate the impact of moderate-to-severe and critical COVID-19 infection on persistence of symptoms and return to work after hospital discharge. In this study, two thirds of hospitalized patients with pulmonary involvement reported persistence of symptoms six months after COVID-19 infection, such as memory loss (45.5%), myalgia (43.9%), fatigue (39.4%), and dyspnea (25.8%), and 50% slowly returned to work, with repercussions due to fatigue and/or loss of energy. [ABSTRACT FROM AUTHOR]

A 44-year-old woman developed mouth sores that persisted for 20 days after having her front teeth extracted a month earlier. No anomalies were found during the general physical examination. Upon intraoral examination, a sessile, purplish nodule measuring 1.3 cm, soft to the touch, and painless, was discovered in the region of the upper incisors. Concurrently, an ulcer in the upper right molar area with raised edges, reddish in color, measuring 2 cm, and being asymptomatic was also observed. Incisional biopsies were performed on both lesions, and they exhibited similar histopathological characteristics. Both lesions were primarily composed of round cells that tested positive for CD138 and demonstrated lambda light chain restriction. They were, however, negative for CD20 and CD3. Based on the cell morphology and the immunohistochemical profile, a final diagnosis of plasmablastic lymphoma was established. Subsequently, the patient was diagnosed with HIV through serological testing and was referred to the hematology team for appropriate treatment. [ABSTRACT FROM AUTHOR]

The specialty of Buccomaxillofacial Prosthesis is responsible for rehabilitating facial extraoral and intraoral losses or malformations stemming from trauma, pathologies, or developmental disorders that cannot be surgically repaired. This clinical case involves a 61-year-old male patient who was diagnosed with squamous cell carcinoma in the soft palate region. He underwent radiotherapy and chemotherapy to remove the malignant neoplasm, which resulted in significant speech difficulties and swallowing challenges. After the removal of all pre-radiotherapy dental elements, complete upper and lower prostheses were fabricated. These prostheses displayed excellent adaptation and satisfactory occlusion, and an adjustment was planned to obturate the upper oropharyngeal region. This adjustment led to an improvement in the patient's speech and swallowing abilities, ultimately restoring his quality of life and enhancing social interaction and reintegration. [ABSTRACT FROM AUTHOR]

The proper preservation of biopsy specimens is crucial for maintaining cellular integrity during histological processing, significantly influencing the quality of immunohistochemical (IHC) and histological analyses. Despite recommendations for 10% buffered formalin as the ideal fixative, pathology labs often receive materials in various solutions. This study assesses the effects of different solutions and temperatures on histological and immunostaining outcomes in IHC reactions, a pivotal diagnostic tool for detecting specific proteins in tissue samples. Skin samples from euthanized Wistar rats were collected and fixed in different solutions (buffered and unbuffered formaldehyde, alcohol, and saline), stored for 24 hours, 7 days, and 30 days. Staining involved Hematoxylin and Eosin, along with Monoclonal Mouse Anti-Human Muscle Actin antibody (Code HHF-35, Dako Denmark). Qualitative and quantitative assessments were conducted. Histological analysis revealed that samples fixed in formalin at room temperature exhibited higher immunostaining and more homogeneous tissue structures than those stored in the refrigerator. Fragments stored in alcohol and saline exhibited reduced immunostaining and tissue autolysis, respectively. Rat skin samples fixed with 10% formalin at room temperature for up to 7 days yielded superior histological and immunohistochemical results, considering cellular expression and integrity. Refrigerated storage increased the incidence of tissue artifacts. This study underscores the importance of optimal storage conditions for preserving tissue quality in histopathological investigations. Valuable insights are provided for pathology laboratories handling diverse fixative solutions, emphasizing the need for adherence to recommended protocols. [ABSTRACT FROM AUTHOR]

This study explores an innovative therapeutic strategy by integrating photodynamic therapy (PDT) and hyperbaric chamber treatment for effective osteonecrosis management. A 65-year-old male with metastatic prostate cancer, receiving Zometa® treatment, presented bilateral mandibular exposed bone, causing pain. A multidisciplinary approach was employed, using topical antiseptics, PDT sessions, and hyperbaric therapy to address the complex condition. During follow-up, the patient underwent sequestrectomy due to bone sequestration. Subsequent tissue repair occurred smoothly, and the patient remained asymptomatic for three years post-treatment. This integrated approach shows promise in managing osteonecrosis, addressing microbial burden, and enhancing tissue repair. PDT and hyperbaric therapy offer a comprehensive solution for osteonecrosis. Further investigations are essential to validate and refine this approach, potentially establishing it as a standard protocol in oral medicine. [ABSTRACT FROM AUTHOR]

This study presents a series of six cases involving patients who underwent previous cancer treatments and utilized bisphosphonates, monoclonal antibodies, and high-dose corticosteroids, subsequently experiencing osteonecrosis in the oral cavity. The associated challenges included pain, recurrent infections, diminished quality of life—especially in terms of food intake—and social discomfort due to characteristic lesion odor. Medication-associated osteonecrosis (OAM) is identified as an injury leading to the temporary or permanent loss of blood supply to bones, with diverse causal factors. Patients underwent thorough anamnesis, substantiating medication use via medical prescriptions, clinical examinations by qualified Dental Surgeons, and imaging assessments including panoramic radiography, periapical radiographs during follow-up, and, in specific cases, computed tomography. The treatment involved weekly monitoring, adjusting consultation frequencies as the condition stabilized, and implementing Sonodynamic Therapy (SDT). SDT, an innovative approach, utilizes low-frequency, high-intensity ultrasound to stimulate sonosensitizers, inducing the formation of reactive oxygen species (ROS). A non-invasive treatment, SDT offers site-specific cytotoxicity by generating ROS in response to sonic/ultrasonic sources, potentially treating bacterial infections. All six patients treated with SDT experienced improved quality of life, as documented through visual evidence. The adaptability of SDT to equipment emitting sonic/ultrasonic waves envisions broader applications, particularly in resource-limited regions, rendering it a potentially accessible method for both professionals and patients. This research underscores the promising outcomes of SDT in managing medication-associated osteonecrosis, paving the way for further exploration and potential integration into broader clinical practices. [ABSTRACT FROM AUTHOR]

Introduction: Treatment for breast cancer can cause adverse effects such as pain and reduced upper limb function which can affect activities of daily living. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is the most used tool for evaluating function in breast cancer survivors. However, some specific aspects have raised discussions about its restricted coverage, which can generate several biases. Objective: To determine if DASH scores differed when assessed before and after task‐oriented training (TOT) at 3 and 6 months after breast cancer surgery. Design: Prospective cohort study. Setting: Institutional study of 22 women assessed at 3 and 6 months after breast cancer surgery. Main Outcome Measures: The DASH questionnaire and TOT assessment. Two correlation tests were performed: Spearman's correlation between the total score of the two DASH scores (pre‐ and post‐TOT) and the Kendall's tau correlation between each of the items. Results: There was a moderate and excellent correlation between final DASH scores, pre‐ and post‐TOT, at both 3 and 6 months postoperatively. However, when assessed individually, most of the DASH items were poorly correlated. There was also no agreement between the total DASH scores pre‐ and post‐TOT as assessed by Bland‐Altman plots. Conclusion: Both the DASH and TOT are considered useful in clinical practice to assess upper limb function, although the use of TOT in some of the DASH items may reduce memory bias and improve skills estimation. [ABSTRACT FROM AUTHOR]

To compare the DNA ploidy profile between the pleomorphic adenoma (PA) in the different clinical stages of its malignant transformation. Forty-six samples divided into the normal salivary gland (control), primary PA, recurrent PA, residual PA, and CXPA were used. Flow cytometric analysis was performed to evaluate the cell percentage among the cell cycle phases. All cell cycle phases showed a statistical difference between the study groups (G1: p<0.001; G2: p=0.009; S: p=0,009; 5cER: p=0,002). In the G1 phase, CXAP obtained a decrease in the percentage of cells compared to primary AP (p=0.003) and recurrent AP (p<0.001) and residual AP showed a decrease compared to recurrent AP (p=0.004). In the S phase, there was a statistical difference between the amount of CXAP and recurrent AP nuclei (p=0.01). Recurrent AP also demonstrated a lower percentage compared to residual (p=0.015) and CXAP (p=0.007) in the 5cER phase. The significant change in the DNA ploidy profile was shown to be a potential differential feature during the malignant progression of PA, while among the frankly benign lesions, no significant changes were observed. [ABSTRACT FROM AUTHOR]

To evaluate DNA content by flow cytometry and Ki-67 index in AB and AC. Cases of AB and AC were retrospectively recovered. The paraffin blocks of the tumors were selected to obtain sections for the immunohistochemical reactions and preparation of the cell suspension for acquisition in a flow cytometer. The Random Forest package of the R software was used to verify the importance of each variable for the diagnosis. 32 cases of AB and 05 of AC were included in this study. The differences in Ki-67 labeling rates were not statistically significant. A higher fraction of cells in 2c (G1) was correlated with the diagnosis of AB while higher rates of 5cER were correlated with AC. The determination of cell percentage thresholds in 2c and 5cER for the predicted outcomes (AB and AC), through multiple logistic regression, showed a cut-off of <63.5% in 2c and >4.2% in 5cER favorable to high risk. The random forest model highlighted histopathological findings and parameters of DNA ploidy study as important features for distinguishing AB from AC. Our findings suggest that the DNA content in tumor cells can be an ancillary tool in the diagnosis of AB and AC. [ABSTRACT FROM AUTHOR]

We aimed to characterize the DNA ploidy and cell cycle phases presented by tumor cells from benign salivary gland neoplasms with myoepithelial/abluminal differentiation. Flow cytometric analysis of the DNA was performed using tissue-extracted cells from paraffin-embedded sections of seventeen pleomorphic adenomas, six basal cell adenomas, five myoepitheliomas, and nine normal salivary glands (control sample). The present study was approved by the research ethics committee (Ref. number: 5.853.891). Females were predominant in all study groups, with an average age between the 5th and 6th decades of life. Most tumors were located in the parotid gland, often presenting as a nodule. Similarly, as in the normal salivary gland, the percentage of cells from the three tumor groups was vastly higher in the G1 phase of the cell cycle, with averages ranging from 79.58% to 81.61%. Through the variance tests, our results demonstrated that there was no statistical difference when comparing the percentages of the cell cycle phases between the groups (Phase G1: p=0.649; Phase S: p=0.503; Phase G2: p=0.517; 5cER: p=0.853). Our results depict a uniformity of DNA ploidy among benign neoplasms similar to that of normal salivary glands. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the accuracy of artificial intelligence (AI) algorithms based on individual epithelial dysplasia (ED) features in predicting malignant transformation (MT) in oral leukoplakia (OL). The microscopic features of cell architecture and atypia were analyzed in 99 cases of OL to identify individual predictors of MT. The associations between each dysplasia feature and MT were evaluated by the Spearman´s test, area under the curve (AUC), as well as accuracy. AI algorithms were developed using Random Forest models. The results showed that loss of cohesion, increased number and size of nucleoli, and inflammation were the single most important predictors of MT. When combined, these 3 features generated AUC=0.73 with a positive predictive value (PPV) of 35% (61% sensitivity, 75% specificity). The AI algorithms identified six key predictors and had a 95% PPV (100% sensitivity and 71% specificity). In conclusion, 3 individual ED features were key predictors, and AI algorithms were significantly superior to traditional methods in establishing MT risk in oral leukoplakia. [ABSTRACT FROM AUTHOR]

Fixation of biopsied materials is a critical step in histological and immunohistochemical processing. However, oral pathology labs often receive improperly collected materials. This study evaluated the effect of different solutions stored at various temperatures on immunostaining in immunohistochemical reactions. Skin from the backs of euthanized Wistar rats was collected using an 8 mm punch pen and placed in different solutions, including buffered and unbuffered formaldehyde, alcohol, and saline, for 24 hours, 7 days, and 30 days. The specimens were then stained with hematoxylin and eosin and the Monoclonal Mouse Anti-Human Muscle Actin antibody (Code HHF-35, Dako Denmark). Histological analysis revealed that specimens fixed in formalin at room temperature had higher immunostaining and more homogeneous tissue structures than specimens stored in the refrigerator. Fragments stored in alcohol and saline had reduced immunostaining and tissue autolysis, respectively. The study concludes that rat skin samples fixed with formalin at room temperature produce better histological and immunohistochemical results. Storage in the refrigerator resulted in a higher incidence of tissue artifacts. Undergraduate research scholarship CNPq/PIBIC [ABSTRACT FROM AUTHOR]

Adenoid cystic carcinoma is known for its slow growth, painless characteristics, a propensity to invade peripheral nerves, and the potential for metastasis, often accompanied by a high recurrence rate. In this case, a 52-year-old female patient presented with swelling and painful symptoms in the anterior region of the mandible. Upon clinical examination, a hardened tumefaction was observed, covered by intact mucosa, displaying pink and purplish colors. Radiographic examination revealed evidence of bone destruction in the anterior mandibular region. Further investigations included an ultrasound of the affected region and an incisional biopsy, leading to a histopathological report confirming the presence of cystic adenoid carcinoma. Subsequently, the patient was referred to the head and neck team for tumor resection and microsurgical reconstruction. A follow-up has been conducted over the course of one year to monitor the patient's progress and recovery.. [ABSTRACT FROM AUTHOR]

COVID-19 has been associated with long-term complications, including persistent symptoms like anosmia (loss of smell) and ageusia (loss of taste). These symptoms can endure for weeks or even years after the initial infection, affecting patients with both mild and severe COVID-19 cases. Here, we present a case involving a 71-year-old Caucasian female who experienced anosmia and ageusia that began after a COVID-19 infection and persisted for a year. To address this issue, intrabuccal photobiomodulation was administered by irradiating nine points on the lingual dorsum and borders with 3J per point, using 660 and 808nm wavelengths. Additionally, intranasal irradiation was performed in each nostril using 2J with the same wavelengths. This procedure was repeated weekly for a two-month period. The patient used a visual analogue scale to monitor the progress of the treatment. Notably, the patient experienced initial improvement as soon as the day following the first session, with gradual enhancement observed over the following weeks. The patient was followed up for a total of 7 months, during which the functions of smell and taste were fully restored. [ABSTRACT FROM AUTHOR]

A 35-year-old male presented with a one-year history of a growth in the roof of his mouth. His family history included a sister who had succumbed to cancer. Upon intraoral examination, a 4-cm fibrous nodule was discovered at the junction between the hard and soft palate. The nodule was painless, sessile, well-defined, and exhibited a reddish color. An incisional biopsy was performed after aspirating a whitish secretion, leading to the diagnosis of pleomorphic adenoma. Subsequently, the lesion was surgically removed under general anesthesia. However, after 17 years, the patient returned with another 2-cm nodule, which had caused significant bone destruction involving the nasal cavity and right maxillary sinus. An incisional biopsy was conducted, and this time, a diagnosis of carcinoma ex pleomorphic adenoma was made. The patient underwent a maxillectomy and received prosthetic oral and maxillofacial rehabilitation, with a 4-year follow-up. This case highlights the importance of long-term follow-up for patients with a history of salivary gland tumors. [ABSTRACT FROM AUTHOR]

Mammary analogue secretory carcinoma (MASC) is a rare salivary gland tumor with histomorphological characteristics resembling breast secretory carcinoma, initially described by Skalova in 2010. This case report underscores the rarity of the lesion and its location, which plays a crucial role in diagnosis. A 66-year-old Caucasian male presented with a submucosal nodular lesion on the right buccal mucosa, near the commissure. The lesion measured 20mm, had a fibrous consistency, and was asymptomatic. An excisional biopsy was performed on the site, and the diagnosis of MASC was confirmed through histopathology and immunohistochemistry. The patient was subsequently referred to the head and neck surgery team for wider surgical margin resection. Over the course of 5 years of follow-up, no recurrence has been observed. [ABSTRACT FROM AUTHOR]

Tumors originating from minor salivary glands are uncommon, with roughly 25% being malignant. Mucoepidermoid carcinoma ranks as the second most prevalent malignant neoplasm affecting minor salivary glands. A 42-year-old female patient sought medical attention due to discomfort and a burning sensation on her tongue persisting for four months. Upon clinical examination, a painless, firm, whitish-yellowish papule measuring approximately 4mm was observed, situated at the junction between the lateral margin and the dorsum of the tongue, with no palpable cervical lymph nodes. Initial diagnostic considerations included papillitis and benign lymphoepithelial cyst. Subsequently, an excisional biopsy was performed, and the histopathological report confirmed a low-grade intracystic mucoepidermoid carcinoma of minor salivary glands, with clear margins of the neoplasm. The patient was referred to the head and neck specialist team and is currently being monitored in the clinical staging phase, thanks to the early diagnosis and favorable prognosis in managing the condition. [ABSTRACT FROM AUTHOR]

Verrucous Carcinoma is a low-grade variant of oral squamous cell carcinoma. Leukoplakia can be seen on adjacent mucosal surfaces, and verrucous carcinoma is a lesion that can develop from proliferative verrucous leukoplakia (PVL), a high-risk precancerous lesion. The aim of this case is to report an elderly female who presented with a 2-year history of growth on the tongue. Upon intraoral examination, she exhibited a thick, diffuse, well-defined, painless plaque with papillary or verruciform projections on the lateral aspect of the tongue, which had developed within a leukoplakic area. An incisional biopsy was performed, confirming the diagnosis of Verrucous Carcinoma within the leukoplakic area. The patient was referred to the Head & Neck team for surgical treatment, and she should undergo regular monitoring due to the risk of recurrences. [ABSTRACT FROM AUTHOR]

The buccal bifurcation cyst (BBC) is an inflammatory odontogenic cyst that typically develops on the buccal surface of permanent lower molars in children between the ages of 6 and 15. Clinically, it is characterized by sensitivity, edema, periodontal pocketing, and purulent discharge. The purpose of this study is to report a clinical case of an adolescent female with a buccal bifurcation cyst. The patient presented with swelling in the right mandible region, pain upon palpation, and the presence of a periodontal abscess with purulent discharge in the area of tooth 47, which had penetrated through the buccal alveolar bone cortex. Radiographically, a well-defined unilocular radiolucent lesion was associated with the roots of tooth 47. Enucleation was performed, and the pathology report confirmed the diagnosis of BBC. This report aims to raise awareness of this lesion, which affects young individuals and can be surgically managed with minimal complications. [ABSTRACT FROM AUTHOR]

A 66-years old white female presented with a 2-month history of mouth ulcers. Her gums were bleeding and causing discomfort, making oral hygiene difficult. She also reported reddish skin blisters on her back for over a year. The patient reported being seen by several specialists who were unable to reach a diagnosis, and at the time of the examination, a patch test investigation was being conducted due to the hypothesis of an allergy. On intraoral examination, positive Nikolsky sign was observed, with the epithelium detaching easily (attached video). A biopsy was taken for direct immunofluorescence, which lead to a diagnosis of Pemphigus Vulgaris. The patient is currently under medical follow-up with oral corticosteroid (Prednisone) therapy and mouth rinses with 0.05% clobetasol propionate, as well as photobiomodulation, showing significant improvement with disappearance of cutaneous lesions andimprovement of gingival lesions. [ABSTRACT FROM AUTHOR]

Acute Myeloid Leukemia (AML), a malignant neoplasm responsible for the rapid proliferation of abnormal cells in the bone marrow, presents some common signs such as gingival bleeding and purple-colored gum hyperplasia. This clinical case aims to show the importance of the dentist in diagnosing AML. A 57-year-old Caucasian female presented with a complaint of gum pain and bleeding for 60 days. She had fibromyalgia and was taking Fluoxetine and Amitriptyline. On examination, purple hemorrhagic gingival hyperplasia was detected. Full blood count, clotting profile, and HIV serology (suspected Kaposi´s sarcoma) were requested and were within normal parameters. An incisional biopsy was performed, and the diagnosis was AML. This case highlights the importance of diagnosing oral lesions, as laboratory tests may remain normal. The patient was referred for oncology-hematology treatment. [ABSTRACT FROM AUTHOR]

Odontogenic Keratocysts (OKC) arise from proliferation of odontogenic epithelial remnants and are predominantly found in the angle and ramus of the mandible. Few cases have been reported on the soft tissue variant of OKC, such as in the mucosa, skin, and even intramuscularly. This report describes the case of a 20-year-old Caucasian female referred for evaluation of a well-defined, yellowish, sessile, painless, rubbery nodule in the upper anterior labial gingiva. Her dentition was sound including pulp vitality, with no radiographic evidence of hard tissue involvement. Surgical excision was performed, and histopathological examination was compatible with OKC. No recurrence was observed in 5 years. Although research has been performed on this variant of OKC, referred to as Peripheral Odontogenic Keratocyst (POKC), debate regarding its origin and nature remains. The present report contributes to the scarce literature on POKC and offers long-term follow-up data on the successful surgical management of this case. [ABSTRACT FROM AUTHOR]

Peripheral Ossifying Fibroma and Peripheral Odontogenic Fibroma are benign lesions found in the oral cavity, common in adolescents, and may be very similar clinically. Their main difference: origin and tissue composition. This report aims to describe a case of Peripheral Ossifying Fibroma recurrence after 4 years of treatment. A 16-year-old white female presented with a complaint of progressively enlarged gums for 2 months. On intraoral examination, fixed orthodontic appliances were present, and the lesion was in the region of the teeth 43 and 44. It was sessile, fibrous on palpation and whitish-pink in color. An excisional biopsy was performed, which was diagnosed as a Peripheral Odontogenic Fibroma. After 4 years, the patient returned with a recurrent lesion, which was biopsied and diagnosed as a Peripheral Ossifying Fibroma. [ABSTRACT FROM AUTHOR]

Histiocytosis, Rosai-Dorfman and Erdhein-Chester are rare diseases caused by infiltration of histiocytes that can involve one or multiple organs. Diagnosis is made based on imaging and biopsy of the lesions. The immunohistochemistry profile in Langerhans cell histiocytosis includes positivity to S-100 and CD1-A whereas in Erdhein-Chester disease, lesions are positive to CD68 and negative to S-100 and CD1-A. A 60-year-old black female, whose main complaint was teeth loss, reported recent dental implant placement and retroperitoneal fibrosis treated with mycophenolate mofetil. On intraoral examination she had tooth mobility, ulcerated lesions, and alveolar bone loss. An incisional biopsy was performed for which the diagnosis was Langerhans cell histiocytosis proven positive to S-100 and CD1-A. Due to the report of retroperitoneal fibrosis, the patient was referred to hematology, which confirmed the association between Langerhans cell histiocytosis and Erdhein - Chester This case has been under observation for two and a half years. [ABSTRACT FROM AUTHOR]