Abstract Introduction: Chronic kidney disease is usually asymptomatic, and its diagnosis depends on laboratory tests, with emphasis on serum creatinine and proteinuria. Objective: To assess knowledge on the role of serum creatinine as a biomarker of kidney function in a sample of the Brazilian population. Method: Cross-sectional observational study conducted in São Paulo (SP, Brazil), in which a random adult population was interviewed. Results: A total of 1138 subjects were interviewed, with a median age of 36 years old (27–52); 55.1% were female. Regarding the “creatinine” biomarker, 40.6% stated they had never performed such a test. When asked about their knowledge on the usefulness of this exam, only 19.6% knew its function. The other responses were “I don’t know” (71.6%), evaluating heart function (0.9%) and liver function (7.8%). Of those who reported they had already taken a creatinine test, only 29.4% correctly identified the role of creatinine. When dividing the groups into “knows” and “does not know” the function of creatinine, a statistically significant difference (p < 0.05) was observed regarding level of education, female sex, being a healthcare student/worker, having ever measured creatinine, knowing someone with kidney disease and older age. In the multivariate analysis, the main variable related to knowing the creatinine role was having previously taken the test (OR 5.16; 95% CI 3.16–8.43, p < 0.001). Conclusion: There is a significant lack of knowledge about creatinine and its use in checkups. The results indicate that greater efforts are needed from healthcare professionals to raise awareness on the role of serum creatinine.

Resumo Introdução: A doença renal crônica costuma ser assintomática e seu diagnóstico depende da realização de exames laboratoriais, com destaque para a creatinina sérica e pesquisa de proteinúria. Objetivo: Avaliar em uma amostra da população brasileira o conhecimento sobre o papel da creatinina sérica como marcador de função renal. Método: Estudo observacional transversal realizado na cidade de São Paulo (SP, Brasil), em que foi entrevistada uma população adulta aleatória. Resultados: Foram entrevistados 1138 indivíduos, com idade mediana de 36 anos (27–52); 55,1% do sexo feminino. Com relação ao marcador “creatinina”, 40,6% afirmaram que nunca realizaram tal dosagem. Quando questionados quanto ao conhecimento sobre a utilidade desse exame, somente 19,6% sabiam a sua função. As outras respostas foram “não sei” (71,6%), avaliar o funcionamento do coração (0,9%) e fígado (7,8%). Dos que afirmaram já terem realizado o exame de creatinina, somente 29,4% acertaram a função da creatinina. Ao dividir os grupos em “sabe” e “não sabe” a função da creatinina, percebeu-se diferença estatisticamente significante (p < 0,05) em relação ao grau de escolaridade, sexo feminino, ser aluno/trabalhador da saúde, ter dosado creatinina alguma vez, conhecer alguém com doença renal e maior idade. Na análise multivariada, a principal variável relacionada com conhecer a função da creatinina foi ter realizado o exame anteriormente (OR 5,16; IC 95% 3,16–8,43, p < 0,001). Conclusão: Há grande desconhecimento sobre a creatinina e seu uso em check-ups. Os resultados indicam que é necessário maior esforço por parte dos profissionais de saúde para divulgar o papel da creatinina sérica.

Abstract Objective: After Endoscopic Sinus Surgery (ESS), packing plays an important role in wound healing and hemostasis. However, the effect of the packing removal procedure on physician stress has not been evaluated. The purpose of this study was to evaluate physician stress during packing removal for patients treated with AQUACEL® Ag Advantage versus KALTOSTAT®. Methods: This retrospective study included 15 patients who underwent packing with ESS for chronic rhinosinusitis performed at two centers; 9 were treated with AQUACEL® Ag Advantage and 6 were treated with KALTOSTAT®. Physician stress during packing removal was evaluated with the National Aeronautics and Space Administration-Task Load Index (NASA-TLX). The time required to remove the packing and the number of instruments used in the procedure were recorded. Postoperative bleeding (Boezaart bleeding score) and wound healing were graded. Patient symptoms on the day after surgery and pain during packing removal were assessed using a visual analog scale. Results: Computed tomography scores, asthma complications, and blood eosinophil counts were significantly higher in the AQUACEL® Ag Advantage group. Patient symptoms on the day after surgery were not significantly different between the two groups. Physician stress during the task of packing removal was significantly lower in the AQUACEL® Ag Advantage group than in the KALTOSTAT® group (35.5 vs. 81.0, p = 0.016) according to the NASA-TLX scores. The number of instruments used in the procedure was significantly lower in the AQUACEL® Ag Advantage group than in the KALTOSTAT® group (3.0 vs. 6.0, p = 0.015). There were no significant differences in procedure time for packing removal, postoperative bleeding, wound healing, or patient pain at the time of packing removal between the groups. Conclusion: Physicians feel stressed about packing removal. In addition, AQUACEL® Ag Advantage is useful for packing after ESS, requiring fewer instruments for the procedure than KALTOSTAT® and reducing physician stress about the procedure. Level of evidence: Level 3.

Objectives: To explore differences in regional cortical morphometric structure between adolescents at risk for depression or with current depression. Methods: We analyzed cross-sectional structural neuroimaging data from a sample of 150 Brazilian adolescents classified as low-risk (LR) (n=50) or high-risk (HR) for depression (n=50) or with current depression (n=50) through a vertex-based approach with measurements of cortical volume (CV), surface area (SA), and cortical thickness (CT). Differences between groups in subcortical volume and in the organization of networks of structural covariance were also explored. Results: No significant differences in brain structure between groups were observed in whole-brain vertex-wise CV, SA, or CT. Also, no significant differences in subcortical volume were observed between risk groups. In relation to the structural covariance network, there was an indication of an increase in the hippocampus betweenness centrality index in the HR group network compared to the LR and current depression group networks. However, this result was only statistically significant when applying false discovery rate correction for nodes within the affective network. Conclusion: In an adolescent sample recruited using an empirically based composite risk score, no major differences in brain structure were detected according to the risk and presence of depression.

Abstract A male patient was scheduled for urgent amputation of his right forearm. His right forearm was stuck inside the insertion slot of a meat grinder, resulting in severe pain to his injured arm. His upper body could not move to sit in a semi-upright position. An endotracheal tube was successfully placed after rapid sequence intubation using a video laryngoscope from behind the patient on the first attempt. This case report is the first documentation of successful anesthetic induction with subsequent endotracheal intubation using a video laryngoscope from behind an injured patient whose upper body was upright with limited positioning. grinder arm semiupright semi position attempt positioning

Abstract Background Cardiovascular diseases (CVD) are the leading cause of morbidity and mortality statistics in Brazil and worldwide. The evaluation of the temporal and spatial distribution of mortality due to CVD is essential to support actions aimed at monitoring the implementation of health policies. Objectives To analyze the temporal trend of mortality due to CVD from 2009 to 2019, as well as the main causes of death according to gender and age group in nine cities of Rio Grande do Sul (RS). Methods This is an ecological study based on data from the Mortality Information System. The rates were stratified according to gender, age group and cause, which were composed of ischemic heart diseases (IHD), cerebrovascular diseases and hypertensive diseases (HD). Prais-Winsten regression was used for time trend estimates. Results Three out of the nine cities analyzed showed a significant reduction in the overall mortality rates due to CVD in the timeframe evaluated (p<0.05). When the cause of death was analyzed, there was a decreasing trend in mortality due to IHD in Caxias do Sul, Ijuí and Porto Alegre. In these cities and also in Passo Fundo and Uruguaiana, there was a decrease in mortality due to cerebrovascular diseases. The cities of Ijuí, Porto Alegre and Santa Maria recorded an increase in hypertensive disease mortality rates. In most cities, there was an increase in rates related to greater age and male sex. Conclusion Heterogeneity was observed in the trend of mortality due to CVD throughout the historical series, which may be related to the execution of public policies and the control of cardiovascular risk factors in the evaluated territories.

Abstract The University Pharmacy Program (FU), from the Federal University of Rio de Janeiro (UFRJ), was created based on the need to offer a curricular internship to students of the Undergraduate Course at the Faculty of Pharmacy. Currently, it is responsible for the care of about 200 patients/day, offering vacancies for curricular internships for students in the Pharmacy course, it has become a reference in the manipulation of many drugs neglected by the pharmaceutical industry and provides access to medicines for low-income users playing an important social function. Research is one of the pillars of FU-UFRJ and several master and doctoral students use the FU research laboratory in the development of dissertations and theses. As of 2002, the Pharmaceutical Care extension projects started to guarantee a rational and safe pharmacotherapy for the medicine users. From its beginning in 1982 until the current quarantine due to the COVID-19 pandemic, FU-UFRJ has been adapting to the new reality and continued to provide patient care services, maintaining its teaching, research, and extension activities. The FU plays a relevant social role in guaranteeing the low-income population access to special and neglected medicines, and to pharmaceutical and education services in health promotion.

Abstract Hydrogels are used for wound treatment, as they may contain one or more active components and protect the wound bed. Papain is one of the active substances that have been used with this purpose, alongside urea. In this paper, carboxypolymethylene hydrogels containing papain (2% and 10% concentrations) and urea (5% concentration) were produced. Physical-chemical stability was performed at 0, 7, 15 and 30 days at 2-8ºC, 25ºC and 40ºC, as well as the rheological aspects and proteolytic activity of papain by gel electrophoresis. Clinical efficacy of the formulations in patients with lower limb ulcers was also evaluated in a prospective, single-center, randomized, double-blind and comparative clinical trial. The results showed 7-day stability for the formulations under 25ºC, in addition to approximately 100% and 15% of protein activity for 10% and 2% papain hydrogel, respectively. The rheological profile was non-Newtonian for the 10% papain hydrogel tested. There were no significant differences regarding the mean time for healing of the lesions, although 10% papain presented a better approach to be used in all types of tissue present in the wound bed.

Abstract The objective of this paper was to develop and evaluate two semi-solid pharmaceutical forms containing 0.1% tacrolimus: cream (CRT01) and gel (GLT01). For the evaluation of physicochemical stability, at times 0, 30, 60 and 90 days, at 23°C and at 40°C, High Performance Liquid Chromatography coupled with a Diode Array Detector (HPLC-DAD) was employed. This method was developed and validated for tacrolimus quantification. The occlusivity test and skin permeation assay were also performed, using an animal model (Wistar rats), and the CRT01 and GLT01 were compared to the 0.1% tacrolimus ointment (PFU01) obtained from the University Pharmacy, Federal University of Rio de Janeiro, Brazil. CRT01 and GLT01 presented a homogeneous aspect and consistency adequate for topical products, along with sensory characteristics above PFU01. They also presented adequate physicochemical stability for 90 days and a lower occlusive effect than PFU01 (p<0.05). CRT01 showed greater affinity for the skin when compared to PFU01 and GLT01, with low systemic absorption. The CRT01 semi-solid formulation was considered the most adequate one to treat patients with atopic dermatitis or other dermatologic inflammatory diseases, promoting rational use of tacrolimus.

Abstract The incorporation of antioxidants into sunscreens may provide additional skin photoprotection against the harmful photobiological effects of ultraviolet radiation. The present study evaluated the applicability of a screening approach to the assessment of the antioxidant and photoprotective properties of vitamin C, vitamin E, and coenzyme Q10 and then determined the performance of the most effective antioxidant in a sunscreen formulation. Antioxidant activity was assessed by the 2,2-diphenyl-1-picrylhydrazyl (DPPH) assay, 2,2`-azino-bis (3-ethylbenzothiazoline-6-sulfonic acid) (ABTS) assay, and oxygen radical absorbance capacity (ORAC) assay, and the photoprotective potential was investigated by the yeast photoprotection assay. The antioxidant with the best effect was incorporated into sunscreen formulations which were evaluated for 120 days regarding their in vitro photoprotective parameters. Vitamin C showed high antioxidant capacity as well as a photoprotective potential against simulated solar irradiation applied for times longer than 1 h. Although the Sun Protection Factor, UVA/UVB ratio and critical wavelength did not differed significantly (p<0.05) between the formulation blank and the formulations containing 0.5% or 1% vitamin C, formulations with vitamin C kept their photostability for 6 months. Consequently, the proposed screening approach seems to be promising for the development of an antisolar photostable formulation containing vitamin C as an antioxidant.

Abstract Background: Postoperative nausea and vomiting (PONV) are major complications after general anesthesia. Although various pathways are involved in triggering PONV, hypotension plays an important role. We hypothesized that intraoperative hypotension during general anesthesia might be responsible for the incidence of PONV. Methods: We retrospectively investigated patients who underwent thyroidectomy. The initial blood pressure measured before induction of anesthesia was used as the baseline value. The systolic blood pressure measured during the operation from the start to the end of anesthesia was extracted from anesthetic records. The time integral value when the measured systolic blood pressure fell below the baseline value was calculated as area under the curve (AUC) of s100%. Results: There were 247 eligible cases. Eighty-eight patients (35.6%) had PONV. There was no difference in patient background between the patients with or without PONV. Univariate analysis showed that the total intravenous anesthesia (TIVA) (p = 0.02), smoking history (p = 0.02), and AUC-s100% (p = 0.006) were significantly associated with PONV. Multiple logistic regression analysis revealed that TIVA (OR: 0.54, 95% CI: 0.29–0.99), smoking history (OR: 0.60, 95% CI: 0.37–0.96), and AUC-s100% (OR: 1.006, 95% CI: 1.0–1.01) were significantly associated with PONV. Conclusion: Intraoperative hypotension evaluated by AUC-s100% was related to PONV in thyroidectomy.

ABSTRACT Cardiovascular disease is the main cause of death in patients with chronic kidney disease (CKD). Several heart conditions have been associated with CKD, including myocardial and pericardial diseases. This paper describes a case of Dialysis-related constrictive pericarditis in a patient diagnosed with sudden hypotension during a hemodialysis session. A 65-year-old man diagnosed with hypertension, diabetes, obesity, and cirrhosis on hemodialysis for two years complained of symptoms during one of his sessions described as malaise, lipothymia, and confusion. The patient had a record of poor compliance with the prescribed diet and missed dialysis sessions. He was sluggish during the physical examination, and presented hypophonetic heart sounds, a blood pressure of 50/30mmHg, and a prolonged capillary refill time. The patient was referred to the intensive care unit and was started on antibiotics and vasoactive drugs. His workup did not show signs of infection, while electrocardiography showed low QRS-wave voltage. His echocardiogram showed signs consistent with a thickened pericardium without pericardial effusion. Cardiac catheterization showed equalization of diastolic pressures in all heart chambers indicative of constrictive pericarditis. The patient underwent a pericardiectomy. Examination of surgical specimens indicated he had marked fibrosis and areas of dystrophic calcification without evidence of infection, consistent with Dialysis-related constrictive pericarditis. Hypotension for unknown causes must be considered in the differential diagnosis of dialysis patients.

RESUMO A doença cardiovascular é a principal causa de morte em pacientes com doença renal crônica (DRC). Várias formas de acometimento cardíaco têm sido associadas. à DRC, incluindo doenças miocárdicas e pericárdicas. Este artigo descreve um caso de pericardite constritiva relacionada a em um paciente diagnosticado com hipotensão súbita durante uma sessão de hemodiálise. Um homem de 65 anos com diagnósticos prévios de hipertensão, diabetes, obesidade e cirrose em hemodiálise por dois anos queixou-se de sintomas durante uma de suas sessões, descritos como mal-estar, lipotímia e confusão mental. Apresentava histórico de baixa adesão à dieta prescrita e faltas frequentes às sessões de diálise. Ele estava fraco durante o exame físico e apresentava bulhas cardíacas hipofonéticas, pressão arterial de 50/30mmHg e tempo de enchimento capilar prolongado. O paciente foi encaminhado para a unidade de terapia intensiva e iniciou o tratamento com antibióticos e drogas vasoativas. Investigação laboratorial não mostrou sinais de infecção, enquanto o eletrocardiograma mostrou baixa voltagem de complexo QRS. Seu ecocardiograma evidenciou sinais consistentes com um pericárdio espessado, sem derrame pericárdico. O cateterismo cardíaco mostrou equalização das pressões diastólicas em todas as câmaras cardíacas, indicativo de pericardite constritiva. O paciente foi submetido a uma pericardiectomia. O exame anatomopatológico mostrou sinais de acentuada fibrose acentuada fibrose e áreas de calcificação distrófica sem evidência de infecção, consistente com pericardite constritiva relacionada a por diálise. A hipotensão por causas desconhecidas deve ser considerada no diagnóstico diferencial de pacientes em diálise.

ABSTRACT The objective of this work is to further the knowledge of gut fungi, inhabiting the digestive tract of mandibulated arthropods, traditionally the Trichomycetes (currently Kicksellomycotina), in Argentina. The geographical distribution of these endobionts, especially in aquatic insects, but also other arthropods, is updated as well as host records and site information. Fungal species (Harpellales), which mostly colonize immature stages of aquatic insects, were identified in members of Coleoptera, Diptera, Ephemeroptera, Plecoptera, and Trichoptera from different biogeographical regions, from the far North in Jujuy province to the southernmost point in Tierra del Fuego. The overall goal of this review is to consolidate all the published and unpublished records from the country in order to summarize their geographical distribution.

RESUMEN El objetivo de este trabajo es reunir toda la información publicada hasta el momento referida a este grupo de hongos, tradicionalmente conocidos como Trichomycetes (actualmente Kicksellomycotina), de la Argentina. El objetivo fue realizar un estado de avance sobre la distribución geográfica de estos endobiontes, especialmente viviendo en insectos acuáticos, pero también en otros artrópodos, con la actualización de registros de hospedadores e información de los sitios de recolección. Las especies de Harpellales colonizan estados inmaduros de insectos acuáticos y fueron identificados en miembros de Coleoptera, Diptera, Ephemeroptera, Plecoptera, y Trichoptera, de diferentes regiones biogeográficas desde el extremo Norte en la provincia de Jujuy al extremo más al Sur en Tierra del Fuego. El objetivo principal de este trabajo es consolidar todos los registros del material publicado y no publicado de la Argentina para resumir su distribución geográfica y lista de especies citadas.

RESUMO O objetivo deste estudo foi avaliar o crescimento vegetativo e produtivo de duas variedades de tomateiro (‘Compack’ e ‘Gaúcho’) com adubação orgânica de duas fontes: cama de aviário (CA) e dejeto líquido de suínos (DLS), com e sem suplementação mineral. O delineamento experimental foi em blocos casualizados com sete tratamentos e quatro repetições para o ‘Compack’ e cinco repetições para o ‘Gaúcho’. Os tratamentos utilizados foram: testemunha, adubação 100% mineral, 100% orgânico de cama de aviário - CA, 100% orgânico de dejeto líquido suíno - DLS, cama de aviário e complementação mineral, 50% de dejeto líquido suíno e complementação mineral e CA 50% complementada com DLS. Aos 30 e 90 dias após o transplantio foram realizadas medidas de altura, largura dos folíolos e diâmetro do caule. Por ocasião da colheita foram realizadas medidas do diâmetro, comprimento, massa, sólidos solúveis e acidez titulável dos frutos. Também foi realizada análise dos teores de N, P e K dos tecidos foliares. O crescimento vegetativo das duas cultivares foi menor na testemunha. A maior produtividade de tomate ‘Compack’ foi obtida com adubação mineral, CA e DLS com complementação mineral e CA + DLS, enquanto que para o tomate ‘Gaúcho’ a maior produtividade foi obtida com adubação de CA + DLS.

HIGHLIGHTS Combining different sources of organic fertilizers is a viable strategy to balance the nutritional demand for tomato. Tomato can be produced without soluble mineral fertilizers. The effect of organic fertilization depends on the cultivar.

Abstract Background and Aims: Within the polygonal of the Cañón del Río Blanco National Park (PNCRB), very few floristic studies have been carried out, hence, the aim of this research is to contribute to the floristic knowledge of the disturbed tropical montane cloud forest and its ecotones with tropical rain forest and oak forest, located in the Altas Montañas region in Veracruz, Mexico. Methods: The collection of botanical specimens was realized during two periods, the first one from 2012 to 2014 and the second one in 2016, supplementing the list by consulting the collections deposited in the CORU herbarium “Dr. Jerzy Rzedowski Rotter” of the Biological and Agropecuarian Sciences Faculty of the University of Veracruz, those mentioned in the Flora of Veracruz fascicles, and records from the National Herbarium of Mexico MEXU, checked on the Open Data Webpage of the National Autonomous University of Mexico. Key results: 1742 records were obtained, including 136 botanical families, 414 genera and 663 species. The most represented botanical families were Orchidaceae, Asteraceae, Bromeliaceae, Fabaceae, Solanaceae, and Malvaceae. Conclusions: Although this area has a high anthropogenic disturbance, the fragments of the cloud forest and its ecotones in the PNCRB have a great richness of vascular plant species, showing the highest value ever reported in Veracruz state. The floristic list here presented will help to make decisions for conservation of natural resources and/or restoration of the study area.

Resumen Antecedentes y Objetivos: Dentro de la poligonal del Parque Nacional Cañón del Río Blanco (PNCRB), se han llevado a cabo escasos estudios florísticos, por lo que el objetivo del presente trabajo es contribuir al conocimiento florístico del bosque mesófilo de montaña (BMM) perturbado y sus ecotonos con la selva mediana subperennifolia y el bosque de Quercus, ubicado en la región de las Altas Montañas del estado de Veracruz, México. Métodos: Se realizaron colectas de material botánico en dos períodos, el primero entre 2012-2014 y el segundo en 2016; se complementó el listado consultando las colectas depositadas en el herbario CORU “Dr. Jerzy Rzedowski Rotter” de la Facultad de Ciencias Biológicas y Agropecuarias de la Universidad Veracruzana, así como las mencionadas en los fascículos de la Flora de Veracruz para el área de estudio y lo reportado en el Herbario Nacional de México MEXU, en el Portal de Datos Abiertos de la Universidad Nacional Autónoma de México. Resultados clave: Se obtuvieron 1742 registros, en donde se incluyen 136 familias botánicas, 414 géneros y 663 especies. Las familias con mayor riqueza fueron Orchidaceae, Asteraceae, Bromeliaceae, Fabaceae, Solanaceae y Malvaceae. Conclusiones: Aunque es una zona con alta perturbación antropogénica, los fragmentos del BMM en el PNCRB y sus ecotonos presentan una gran riqueza de plantas vasculares, teniendo uno de los valores más altos que se han reportado en el estado de Veracruz. La lista florística que aquí se presenta ayudará para tomar decisiones de conservación sobre los recursos naturales y/o restauración del área de estudio.

Resumo Investigamos a percepção de mulheres gordas sobre seu próprio corpo e suas experiências com discriminações relacionadas ao peso e como essas situações afetavam seu bem-estar. Trinta e nove mulheres obesas foram entrevistadas, sendo identificados três eixos de análise: (1) repercussões de ser gorda, (2) vivendo com um corpo gordo, e (3) eu sou uma pessoa ou apenas um corpo gordo? Esses eixos eram compostos por oito temas que se complementavam ou tinham significado semelhante. Os resultados mostraram que nossas participantes utilizavam mecanismos para diminuir a magnitude de seus corpos estigmatizados (por exemplo, tentando perder peso e modificando suas escolhas alimentares atuais). As participantes também relataram que ser gorda teve consequências físicas e psicológicas para elas. É importante ressaltar que seus corpos maiores influenciaram sua autoavaliação, fazendo com que se sentissem desvalorizadas, incapazes, incompletas e sem possibilidade de se sentirem amadas. Elas relataram experiências estigmatizadoras em situações familiares, no local de trabalho e em espaços públicos, e relataram serem estigmatizadas por pessoas próximas e desconhecidas, bem como por profissionais de saúde. Foi relatado que esses profissionais tratam os pacientes com desrespeito, o que exige atenção quanto às desigualdades na assistência à saúde de pessoas obesas. Nossos resultados enfatizam que atitudes estigmatizadoras em relação às pessoas gordas e suas próprias considerações sobre si mesmas têm consequências negativas para seu bem-estar físico e mental.

Abstract We investigated fat women’s perceptions of their own bodies and their experiences with weight-related discriminations, and how these situations affected their well-being. Thirty-nine obese women were interviewed, and three axes of analysis were identified: (1) repercussions of being fat, (2) living with a fat body, and (3) am I a person or just a fat body? These axes were composed of eight themes which had similar meaning or complemented each other. The results showed our participants had mechanisms to diminish the magnitude of their stigmatized bodies (e.g., attempting to lose weight and changing their current food choices). Participants also reported being fat had physical and psychological consequences for them. Most notably, their larger bodies influenced their self-evaluation, making them feel devalued, unlovable, incapable, and incomplete. They reported stigmatizing experiences in familiar situations, at the workplace and in public spaces, and reported being stigmatized by both close and unknown individuals, including healthcare professionals. These professionals were reported to treat patients disrespectfully, which urges attention to health care inequalities for obese people. Our results stress stigmatizing attitudes towards fat people and their own considerations about themselves have negative consequences in their physical and mental well-being.