RESUMO

OBJECTIVE: To generate normative data for the Verbal Fluency Test (VFT) and the Boston Naming Test (BNT) in the Costa Rican population. METHOD: The sample consisted of 563 healthy older people (aged 59-90 years). Polynomial multiple regression analyses were run to evaluate the effects of the age, sex, and education variables on VFT and BNT scores. RESULTS: The results showed a significant linear effect of education on the four-letter VF scores and an effect of sex on the letter P score, with females performing better than males. The explained variance ranged from 20.9% to 28.3%. A linear effect of age and education was also found for the four semantic VF scores, with scores decreasing with increasing age and lower education. The sex variable was significant for all semantic categories, with females performing better than males except in the animal category. The explained variance ranged from 21.7% to 30.9%. In the BNT, a linear effect of education was found, so that the more education, the better the score. In addition, a sex effect was also found, with males having higher scores than females. The predictors of the model explained 9.6% of the variance. CONCLUSIONS: This is the first study that generates normative data for the VF and BNT in the Costa Rican population over 59 years of age based on demographic variables. The use of these normative data will help clinicians in Costa Rica to better understand language functioning in the elderly, allowing for better classification and diagnosis in the future.

RESUMO

BACKGROUND: Verbal fluency tests (VFT) are highly sensitive to cognitive deficits. Usually, the score on VFT is based on the number of correct words produced, yet it alone gives little information regarding underlying test performance. The implementation of different strategies (cluster and switching) to perform efficiently during the tasks provide more valuable information. However, normative data for clustering and switching strategies are scarce. Moreover, scoring criteria adapted to Colombian Spanish are missing. AIMS: (1) To describe the Colombian adaptation of the scoring system guidelines for clustering and switching strategies in VFT; (2) to determine its reliability; and (3) to provide normative data for Colombian children and adolescents aged 6-17 years. METHODS & PROCEDURES: A total of 691 children and adolescents from Colombia completed phonological (/f/, /a/, /s/, /m/, /r/ and /p/) and semantic (animals and fruits) VFT, and five scores were calculated: total score (TS), number of clusters (NC), cluster size (CS), mean cluster size (MCS) and number of switches (NS). The intraclass correlation coefficient was used for interrater reliability. Hierarchical multiple regressions were conducted to investigate which strategies were associated with VFT TS. Multiple regressions were conducted for each strategy, including as predictors age, age2 , sex, mean parents' education (MPE), MPE2 and type of school, to generate normative data. OUTCOMES & RESULTS: Reliability indexes were excellent. Age was associated with VFT TS, but weakly compared with strategies. For both VFT TS, NS was the strongest variable, followed by CS and NC. Regarding norms, age was the strongest predictor for all measures, while age2 was relevant for NC (/f/ phoneme) and NS (/m/ phoneme). Participants with higher MPE obtained more NC, and NS, and larger CS in several phonemes and categories. Children and adolescents from private school generated more NC, NS and larger CS in /s/ phoneme. CONCLUSIONS & IMPLICATIONS: This study provides new scoring guidelines and normative data for clustering and switching strategies for Colombian children and adolescents between 6 and 17 years old. Clinical neuropsychologists should include these measures as part of their everyday practice. WHAT THIS PAPER ADDS: What is already known on the subject VFT are widely used within the paediatric population due to its sensitivity to brain injury. Its score is based on the number of correct words produced; however, TS alone gives little information regarding underlying test performance. Several normative data for VFT TS in the paediatric population exist, but normative data for clustering and switching strategies are scarce. What this paper adds to existing knowledge The present study is the first to describe the Colombian adaptation of the scoring guidelines for clustering and switching strategies, and provided normative data for these strategies for children and adolescents between 6 and 17 years old. What are the potential or actual clinical implications of this work? Knowing VFT's performance, including strategy development and use in healthy children and adolescents, may be useful for clinical settings. We encourage clinicians to include not only TS, but also a careful analysis of strategies that may be more informative of the underlying cognitive processes failure than TS.

Assuntos

RESUMO

Background: Sexual changes are an area of primary concern for individuals with spinal cord injury (SCI) and their partners, but the topic has gone largely unexplored in the research literature. Objectives: This study examined how individuals with SCI in Latin America experience their sexuality and what issues they and their partners face in this area. Methods: A total of 248 individuals with SCI from Latin America completed an online 60-item survey regarding sexuality. Results: The majority of participants (87.7%) reported that they had noticed changes in sexuality after the injury, mainly physical problems (50.7%), emotional problems (38.7%), and changes in relationships with partners (27.5%). Regarding sexual desire, 47.2% indicated that desire remained the same after SCI. The majority of participants (81.9%) indicated not having received any information about sexuality after SCI during their hospital stay but reported that they would have liked to have received information (98.1%). Of all participants, 66.1% reported never having been asked about problems or difficulties in their sexual life after SCI by any health professional. Conclusion: Interventions designed to educate individuals with SCI regarding the effect of injury on their sexual functioning, responsiveness, and expression, as well as to support them in maintaining and enhancing their sexual well-being, may be extremely beneficial, particularly in Latin America. Findings highlight the distinct need for professionals to introduce the topic of sexuality by discussing it in a straightforward, nonjudgmental manner and to integrate discussions about sex and related issues into assessment, planning, and ongoing treatment.

Assuntos

RESUMO

BACKGROUND: Individuals with traumatic brain injury (TBI) in Latin America experience high levels of disability and extremely poor functional outcomes, and their informal caregivers play a key role in their rehabilitation and care. OBJECTIVE: To improve TBI rehabilitation through stronger informal caregiving, this study developed and evaluated an evidence-based and culturally appropriate Transition Assistance Program (TAP) for informal caregivers of individuals with TBI in Latin America, specifically targeting the time period before and after the transition from hospital to home. METHODS: A sample of 89 people with a new TBI and their primary informal caregiver (n = 178) was recruited from two hospitals in Mexico City, Mexico, and in Cali, Colombia. Caregivers were randomly assigned to either the TAP group or to a control group receiving the standard care provided by the hospital. Caregivers completed measures of depression and burden, and individuals with TBI completed measures of depression and self-perceived burden on caregivers before hospital discharge and at 2- and 4-month follow ups. RESULTS: Caregivers in the TAP group reported significantly lower burden than those in the control group and marginally lower depression. Individuals with TBI whose caregivers had been in the TAP group reported significantly lower depression than those whose caregivers had been in the control group, and a non-significant but lower self-perceived burden on their caregivers. CONCLUSION: The results suggest that the TAP has strong potential to benefit both TBI caregivers and individuals with TBI during the transition from acute TBI hospitalization to home in Latin America, generally showing small-or medium-sized effects on key outcomes.

Assuntos

RESUMO

This is an observational exploratory study assessing self-concept and its association with depression, anxiety, satisfaction with life, and quality of life 6 months after experiencing a traumatic brain injury. Participants were 33 patients who suffered a traumatic brain injury 6 months before the assessment. The measures used in this study were the Repertory Grid Technique, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Satisfaction With Life Scale, and the Quality of Life after Brain Injury. We calculated Euclidean distances to assess differences in pre-and post-injury self-perception, as well as the proportion of opposed pole construct rating and polarization to understand how they are associated with the scores of the other offered measures. We found that the distance between the present and ideal self, as well as the distance between the present self and the self before the lesion showed moderate positive correlations with depression, and negative correlations with satisfaction with life and quality of life. Also, for the present and self before the lesion, the proportion of opposed pole ratings was correlated with depression symptoms, quality, and satisfaction with life, while for the present self and the ideal self this proportion was correlated with all the measures. The proportion of polarization of the present self and the total polarization was negatively correlated with symptom measures. The repertory grid might facilitate a greater understanding of self-concept after traumatic brain injury. This information could be used to guide treatments that address the emotions related to distances observed in the perception of the self.

RESUMO

To our knowledge, this is the first study reported in the literature that has validated the Norma Latina Battery in a population of people with Alzheimer's disease (AD) in Mexico. The objective of the study was to determine the discriminant validity of the Norma Latina Battery in a group of Mexican individuals with AD and a group of heathy controls (HC). The Norma Latina Battery was administered to 234 Mexican participants (117 HC and 117 individuals with AD). Results show that: (1) the Norma Latina Battery has high discriminative capacity between groups in all domains; (2) participants with AD presented worse scores in each of the cognitive domains compared to the HC and a greater number of low scores in each of the established thresholds or cut-off points; and finally, (3) the Norma Latina Battery had optimal sensitivity and specificity, especially when a set was observed ≥5 scores below the 10th percentile or ≥4 scores below the 5th percentile. In conclusion, it is recommended that both clinicians and researchers use this battery in the evaluation of Mexican people with AD to better understand the prognosis of the disease and its subsequent treatment.

Assuntos

RESUMO

BACKGROUND: Between 50-60% of Multiple Sclerosis (MS) patients have cognitive alterations. There are several batteries to assess cognitive impairments in MS, however, few exist for Latin Americans. The objective of this study is to evaluate the neuropsychological profile of Mexican people with MS (PwMS) and assess the utility of Norma Latina, a new battery for cognitive assessment in Latin America, in differentiating cognitive test performance between PwMS and healthy controls (HCs). METHODS: 100 PwMS and 100 HCs from Mexico were evaluated with the Norma Latina battery. The following analyses were conducted: 1) low-percentiles of each participant were calculated, 2) Area Under the Curve was used to determine whether the battery discriminated between PwMS and HCs, 3) four composite scores were calculated, and student's t-test was used to compare groups according to these domains. RESULTS: PwMS obtained a greater number of impaired scores compared to HCs, principally in executive function. The battery successfully discriminated between PwMS and HCs, with the strongest capacity to discriminate in the executive functions, and the weakest in memory. CONCLUSION: Establishing validation of a neuropsychological battery for Mexican PwMS will help to more accurately detect cognitive alterations, which will guide the decisions of professionals in terms of cognitive rehabilitation.

Assuntos

RESUMO

Previous research connecting health-related quality of life (HRQoL) in people with traumatic brain injury (TBI) and caregiver mental health has primarily been conducted cross-sectionally in the U.S. and Western Europe. This study, therefore, examined how HRQoL in individuals immediately after their TBI predicts longitudinal caregiver depression symptom trajectories in Latin America. A sample of 109 patients with an acute TBI and 109 caregivers (total n = 218) was recruited from three hospitals in Mexico City, Mexico, and in Cali and Neiva, Colombia. TBI patients reported their HRQoL while they were still in hospital, and caregivers reported their depression symptoms at the same time and at 2 and 4 months later. Hierarchal linear models (HLM) found that caregiver depression symptom scores decreased over time, and lower patient mental health and pain-related quality of life at baseline (higher pain) predicted higher overall caregiver depression symptom trajectories across the three time points. These findings suggest that in Latin America, there is an identifiable relationship between psychological and pain-related symptoms after TBI and caregiver depression symptom outcomes. The results highlight the importance of early detection of caregiver mental health needs based in part upon patient HRQoL and a culturally informed approach to rehabilitation services for Latin American TBI caregivers.

Assuntos

RESUMO

AIM: Neuropsychological normative data for Latin America have been recently published, and for Colombia, in particular, but longitudinal neuropsychological outcomes after stroke have not yet been examined in this global region. The purpose of the current study was to compare functioning of individuals with stroke in Colombia, South America during the first year post-stroke to healthy controls across neuropsychological assessments of memory, language, and visuoperceptual impairments. METHOD: A sample of 50 individuals with stroke (mean age = 51.58) and 50 matched healthy controls (mean age = 51.54) from Colombia were included in this study. Because of a lack of access to health services, individuals with stroke did not receive any inpatient or outpatient cognitive or behavioral rehabilitation. Participants were assessed on 10 visuoperceptual, language, and memory tasks at 3, 6, and 12 months. RESULTS: Trajectories of neuropsychological performance were significantly worse among individuals with stroke than healthy controls across every index. Further, hierarchical linear models suggested that although both individuals with stroke and controls generally improved over time on these assessments, the improvements among individuals with stroke were often of no greater magnitude than the improvements seen in controls, suggesting extremely low levels of rehabilitation gains in Colombia. Only three of the 10 neuropsychological assessments did a significant time*group interaction occur, suggesting greater gains for the stroke group than controls. CONCLUSION: These findings suggest profound disparities in post-stroke cognitive functioning in Colombia compared to other more developed global region and underscore the importance of comprehensive cognitive rehabilitation services for individuals with stroke in Colombia and other similar global regions. Implications for rehabilitation Because this study found only negligible cognitive improvements beyond practice effects over the first year after stroke in Colombia among individuals without access to acute rehabilitation, it is imperative that comprehensive cognitive rehabilitation services be implemented immediately during the acute rehabilitation period. Memory, language, and visuoperceptual training strategies can be implemented for people with stroke in underserved global regions as part of the standard of care for stroke rehabilitation. Cognitive rehabilitation strategies should be adapted into Spanish and pilot tested in Latin America to ensure cultural equivalence. Culturally competent cognitive rehabilitation strategies should be tailored based on varied educational and literacy levels.

Assuntos

RESUMO

OBJECTIVE: The purpose of this study was to generate normative data for five tests of attention and executive functions (M-WCST, Stroop test, TMT, BTA, and SDMT), in a group of 322 Ecuadorian adults from Quito between the ages of 18 and 85. METHOD: Multiple regression analyzes taking into account age, education, and gender were used to generate the normative data. RESULTS: Age and education were significantly related to test performance such that scores decreased with age and improved as a function of education. An online calculator is provided to generate normative test scores. CONCLUSIONS: This is the first study that presents normative data for tests of executive functions and attention in an Ecuadorian adult population. This data will improve the clinical practice of neuropsychology and help to develop the field in the country.

Assuntos

RESUMO

BACKGROUND: Previous literature has shown disparities between developing and developed regions in executive functioning, attention, and processing speed performance following stroke. Research on post-stroke longitudinal outcomes in Latin America specifically is almost nonexistent. OBJECTIVES: To assess spontaneous recovery among individuals with stroke in the absence of cognitive rehabilitation services in Colombia, South America during the first year post-stroke by comparing their functioning to that of healthy controls across executive functioning, attention, and processing speed at 3, 6, and 12 months. DESIGN: Cohort. SETTING: Stroke rehabilitation center at the regional hospital. PARTICIPANTS: A sample of 50 individuals with stroke and 50 matched healthy controls from Colombia were included in this study. Consistent with the healthcare resources in this region, participants did not receive any inpatient or outpatient cognitive rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Executive functioning, attention, and processing speed. RESULTS: Hierarchical linear models suggested improvements over time for both individuals with stroke and controls, but trajectories of neuropsychological performance were significantly lower for individuals with stroke. Only on one of nine outcomes was there a significant time*group interaction, suggesting greater gains for the stroke group than controls. CONCLUSIONS: These data suggest extremely minor spontaneous recovery among individuals with stroke in Colombia relative to practice effects in controls, and that apparent improvements in executive functioning after stroke were likely just due to practice effects. These findings underscore the bleak outcomes in cognitive functioning after stroke that occur in regions without cognitive rehabilitation.

Assuntos

RESUMO

BACKGROUND: With structured interviews being an established method for assessing one's exposure to traumatic brain injury across their lifetime, effective assessment tools are needed to serve the large population of Spanish speakers in the U.S. and abroad. OBJECTIVE: To obtain preliminary evidence of validity for a Spanish version of a web-based, structured interview designed to assess lifetime exposure to TBI. METHODS: A sample of 720 Spanish-speaking individuals between the ages of 18 through 65 from the continental U.S. (34.3%), South America (30.8%), the Caribbean (12.6%), Spain (12.4%), and Mexico and Central America (9.9%) completed an online survey containing the Ohio State University Traumatic Brain Injury Identification Method (Self-Administered-Brief; OSU TBI-ID SAB), Neurobehavioral Symptom Inventory, and PROMIS Cognitive Concerns Scale. RESULTS: Indices of severity of worst TBI, time since most recent TBI, and multiple injuries demonstrated expected relationships with neurobehavioral symptoms such that greater symptom reporting was observed among those who had more severe injuries, more recent injuries, and multiple injuries over a period of time. CONCLUSIONS: Findings provide preliminary evidence of validity for three of the indices derived from OSU TBI-ID SAB among Spanish-speaking individuals. Further study is needed to assess other aspects of this instrument to pave the way for further epidemiological studies involving lifetime exposure to TBI among Spanish-speaking individuals across the U.S., Spain, and Latin America.

Assuntos

RESUMO

Pediatric traumatic brain injury (TBI) represents a serious public health concern. Family members are often caregivers for children with TBI, which can result in a significant strain on familial relationships. Research is needed to examine aspects of family functioning in the context of recovery post-TBI, especially in Latin America, where cultural norms may reinforce caregiving by family members, but where resources for these caregivers may be scarce. This study examined caregiver-reported family satisfaction, communication, cohesion, and flexibility at three time points in the year post-injury for 46 families of a child with TBI in comparison to healthy control families. Families experiencing pediatric TBI were recruited from a large hospital in Guadalajara, Mexico, while healthy controls were recruited from a local educational center. Results from multilevel growth curve models demonstrated that caregivers of children with a TBI reported significantly worse family functioning than controls at each assessment. Families experiencing pediatric TBI were unable to attain the level of functioning of controls during the time span studied, suggesting that these families are likely to experience long-term disruptions in family functioning. The current study highlights the need for family-level intervention programs to target functioning for families affected by pediatric TBI who are at risk for difficulties within a rehabilitation context.

Assuntos

RESUMO

PURPOSE: The main aim was to evaluate the measurement properties of the Family Needs Questionnaire-Revised (FNQ-R) in family members of individuals living with severe traumatic brain injury (TBI). METHODS: A total of 309 family members of individuals with severe TBI from Colombia, Denmark, Mexico, Norway and Spain participated. Rasch analysis of the FNQ-R and its 6 subscales was conducted. RESULTS: The Rasch analysis indicated a lack of fit of the 37-item FNQ-R to one single underlying construct of needs, and less than half of the items were invariant across the countries. Misfit of single items was revealed in the Need for Health Information, Need for Emotional Support, Need for Instrumental Support, Need for Professional Support and Need for Community Support Network subscales. Fit to the Rasch model was obtained after removal of misfitting items. The Involvement in Care subscale had too few items to be adequately assessed by the Rasch approach. CONCLUSION: The FNQ-R is a well-targeted instrument for assessing the unmet needs of caregivers regarding the need for health information, emotional support, professional support and a community support network after some scoring adjustment and the removal of misfitting items. Caution should be taken when comparing responses across countries.

Assuntos

RESUMO

Latin America has high rates of traumatic brain injury (TBI), yet reduced mental and physical health outcomes due to limited rehabilitation services. To understand the psychosocial adjustment process in TBI patients in Latin America, the incorporation of cultural values including family-based variables is imperative. The current study examined relations among healthy family dynamics, coping, and mental and physical health related quality of life (HRQL) among a sample of TBI patients across three sites and two countries over the first 4 months post-injury. A sample of 109 acute TBI patients from Mexico and Colombia were recruited, and a series of longitudinal mediation and cross-lag panel analyses were run. Mental and physical HRQL were positively associated with each other, as well as healthy family dynamics and coping. Coping partially mediated the effects of healthy family dynamics on both mental and physical HRQL. Family dynamics showed the strongest cross-lag relationships with coping going from 2 months to 4 months. Similarly, coping showed the strongest cross-lag relationships with both mental and physical HRQL going from baseline to 2 months. Results provide empirical support for the importance of a rehabilitation workforce that has been trained in and can effectively implement family-based interventions for individuals with TBI in Latin America.

Assuntos

RESUMO

Objective: To generate normative data for verbal fluency and naming test in an Ecuadorian adult population. Methods: The sample consisted of 322 healthy adults (18-84 years old) recruited from Quito, Ecuador. The verbal fluency and Boston Naming Test (BNT) were administered as part of a larger comprehensive neuropsychological battery. Multiple linear regression analyses were used to generate the normative data taking into account age, education, and sex. Results: For phonological verbal fluency, results indicated that only education was significantly related to the performance of the letters "A," "S," and "M." However, the performance on the letter "F" was significantly associated with age and education. For semantic fluency, the performance on "animals" was significantly influenced by age, quadratic age, and education, whereas that for "fruits" was explained by quadratic age, education, and sex. The performance on the BNT was significantly influenced by age and education. A Microsoft Excel-based calculator was created to help clinicians to obtain the normative data on this test. Conclusion: This normative data will help neuropsychologist in Ecuador to use these tests both in research and in their clinical practice to improve the diagnosis of cognitive deficits in the population.

RESUMO

OBJECTIVE: The objective of this study was to develop norms for two neuropsychological tests of learning and memory in an Ecuadorian adult population. METHOD: 322 healthy individuals, ages between 18 and 84, were enrolled in the Metropolitan District of Quito. Participants were administered a comprehensive neuropsychological evaluation that included tests of learning and memory (Rey-Osterrieth Complex Figure Test [ROCF] and Hopkins Verbal Learning Test-Revised [HVLT-R]). Backward stepwise multiple linear regression analyses were used to examine the influence of demographic variables age, education, and gender on test performance. Normative data were developed adjusting for demographic variables found to be significant in the final regression models. RESULTS: The final multiple linear models revealed performance on tests of learning and memory worsened with age and improved as a function of education. A user-friendly Excel-based calculator is presented to calculate the z score and percentile automatically based on raw score and sociodemographic information. CONCLUSION: This is the first study that presents normative data for tests of learning and memory for an adult population in Ecuador. It is expected that these norms will help to improve the clinical practice of neuropsychology in Ecuador by limiting erroneous raw score interpretation and incrementing diagnostic accuracy.

Assuntos

RESUMO

OBJECTIVE: Traumatic brain injury represents a major public health concern, particularly in low- and middle-income countries like in Latin America. Family members are often caregivers for individuals with traumatic brain injury, which can result in significant stress. Research is needed to examine depression and quality of the caregiving relationship in these dyads. This study examined relationship quality and depression longitudinally after traumatic brain injury within the caregiving relationship. DESIGN: Dyads (N = 109) composed of individuals with traumatic brain injury and their caregivers were recruited from three hospitals in Mexico and Colombia. They self-reported depression and relationship satisfaction during hospitalization and at 2 and 4 mos after hospitalization. RESULTS: A 2-lag Actor Partner Interdependence Model demonstrated that patients and caregivers reporting high relationship satisfaction at baseline experienced lower depression 2 mos later, which then predicted higher caregiver relationship satisfaction at 4 mos. Moreover, patients with high relationship satisfaction at baseline had caregivers with lower depression at 2 mos, which was then associated with patients' higher satisfaction at 4 mos. CONCLUSIONS: Within individuals with traumatic brain injury and caregivers, depression and relationship satisfaction seem to be inversely related. Furthermore, patients' and caregivers' depression and relationship satisfaction impact each other over time, demonstrating interdependence within the caregiving relationship.

Assuntos

RESUMO

The characteristics and current situation of pediatric neuropsychologists across Spanish-speaking countries was examined. A total of 409 self-identified professionals working in child neuropsychology from 12 Latin American countries and Spain completed an online survey between June and October 2018. Results revealed that pediatric neuropsychology as a related but distinct discipline within neuropsychology presents with a series of unique challenges to practitioners in Spanish-speaking countries. Efforts and initiatives are required to increase awareness of the field, define the core competencies, foster more opportunities for training, and conduct research to understand sociocultural characteristics and develop culturally specific tools.

Assuntos

RESUMO

BACKGROUND: Latin America has exceptionally high rates of traumatic brain injury (TBI), but very little research has been conducted on longitudinal TBI outcomes in this global region. OBJECTIVE: This study examined whether cognitive dysfunction and social disadaptation in individuals with TBI in Latin America at hospital discharge predict longitudinal trajectories of depression at baseline, 2 months, and 4 months. METHODS: A sample of 109 people with a new TBI was recruited from three hospitals: Mexico City, Mexico, Cali, Colombia and Neiva, Colombia. Participants completed measures of cognitive dysfunction and social disadaptation before hospital discharge and measures of depression at baseline, 2 months, and 4 months. RESULTS: Results suggested that depression scores were found to decrease over time in a quadratic (or U-shaped) fashion, and more significant cognitive dysfunction at hospital discharge was associated with higher longitudinal depression trajectories. Social disadaptation did not exert a unique effect on depression trajectories after controlling for cognitive dysfunction. Depression trajectories changed differentially over time as a function of baseline cognitive dysfunction, such that for those with high cognitive impairment, depression scores started high and then dropped to a moderated range and plateaued, but for individuals with low cognitive dysfunction, depression scores started lower and decreased linearly but moderately. CONCLUSIONS: The results suggest a strong need for neuropsychological assessments and evidence-based cognitive rehabilitation strategies to be implemented immediately after TBI in Latin America, which could exert salubrious effects on depression trajectories over time.

Assuntos