Disaster Management in a Nephrology Service: Lessons Learned from Hurricane Maria.

BACKGROUND: Puerto Rico suffered a major humanitarian -crisis after Hurricane Maria. We describe our experience with patients with renal disease in an academic medical center. SUMMARY: A comprehensive emergency response plan should be developed, shared and discussed with the team and the patients prior to the hurricane. The needs of the staff should not be ignored to ensure their ability to participate as responders. Physical damage to facilities, lack of basic services, shortage of disposable products, and the inability to get to treatment centers are the most common threats. Preemptive dialysis can avoid serious complications. A contingency plan to move patients to another center should be prearranged in case the unit is rendered nonfunctional after the storm. Patients must receive preventive education about fluid and dietary restrictions and the possible use of potassium binding drugs if they cannot reach a dialysis unit. A list of alternative drugs that could be used if patients are not able to fill their medications is required. The Internet and social media proved to be an invaluable communication tool. A registry of patients with updated contact information, as well as contact information for relatives and a physical address where an emergency rescue team can be dispatched is essential. Water safety should be reinforced. Key Message: Our experience showed us that preparing for the worst is not enough. Advanced planning of a streamlined response is the best tactic to decrease harm.

Vitamin D deficiency is common and is associated with overweight in Mexican children aged 1-11 years.

OBJECTIVE: To assess vitamin D dietary sources, intake and 25-hydroxyvitamin D status and their association with individual and sociodemographic characteristics in Mexican children. DESIGN: Data obtained from 2695 children aged 1-11 years from the Mexican National Health and Nutrition Survey (2012) were analysed. Diet was assessed by a 141-item FFQ. 25-Hydroxyvitamin D was measured by a chemiluminescent assay. RESULTS: Mean vitamin D intake was 3·38 (se 0·09) µg/d (135·2 (se 3·6) IU/d) among pre-school children and 2·85 (se 0·06) µg/d (114·0 (se 2·4) IU/d) in school-age children. Milk accounted for 64·4 % of vitamin D intake in pre-school children and 54·7 % in school-age children. Vitamin D deficiency (serum 25-hydroxyvitamin D<50 nmol/l) was 25·9 % in pre-schoolers and 36·6 % in school-age children. Overweight/obese school-age children had a higher risk of vitamin D deficiency compared with normal-weight children (OR=2·23; 95 % CI 1·36, 3·66; P<0·05). CONCLUSIONS: Vitamin D intakes are low in Mexican children, and milk is the main source of the vitamin. Vitamin D deficiency is common and associated with overweight in school-age children.

Indigenous tropical spastic paraparesis in Madrid (Spain). Experience on screening of human T-lymphotropic virus. / Paraparesia espástica tropical autóctona en la Comunidad de Madrid. Experiencia en el cribado del virus linfotrópico de células T humanas tipo I.

We have recently documented a case of tropical spastic paraparesis by HTLV-I in a Spanish patient. HTLV-I infection is rare in Europe, and hardly ever is accompanied by symptoms, but if it does it could trigger a major health issue. This case is presented here, as well as a discussion on the situations in which HTLV-I detection is justified. An analysis was made of the HTLV diagnostic requests at our centre during 2014-2015 (n=123). The diagnostic algorithm was: 1) Enzyme immunoassay, 2) Reverse hybridization, and 3) Proviral DNA detection by PCR. The results showed several situations of HTLV screening, emphasising those related to paraparesis (22%). Seven cases of HTLV-I infection were found: five in patients from endemic regions, one in an HIV-infected patient, and the case of TSP mentioned above. HTLV-I surveillance in non-endemic regions is a challenging issue, as the cost-benefit ratio is not well-established. This case report emphasises the importance of including HTLV within the differential diagnosis of insidious spastic paraparesis.

Pediatric Risk, Injury, Failure, Loss, End-Stage renal disease score identifies acute kidney injury and predicts mortality in critically ill children: a prospective study.

OBJECTIVES: To determine whether Pediatric Risk, Injury, Failure, Loss, End-Stage renal disease (pRIFLE) criteria serve to characterize the pattern of acute kidney injury in critically ill pediatric patients. To identify if pRIFLE score will predict morbidity and mortality in our patient's cohort. DESIGN: Prospective cohort. SETTING: Multidisciplinary, tertiary care, ten-bed PICU. PATIENTS: A total of 266 patients admitted to PICU from November 2009 to November 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The incidence of acute kidney injury in the PICU was 27.4%, of which 83.5% presented within 72 hours of admission to the PICU. Patients with acute kidney injury were younger; weighed less; were more likely to be on fluid overload greater than or equal to 10%; and were more likely to be on inotropic support, diuretics, or aminoglycosides. No difference in gender, use of other nephrotoxins, or mechanical ventilation was observed. Fluid overload greater than or equal to 10% was an independent predictor of morbidity and mortality. In multivariate analysis, acute kidney injury and failure categories, as defined by pRIFLE, predicted mortality, hospital length of stay, and PICU length of stay. CONCLUSIONS: In this cohort of critically ill pediatric patients, acute kidney injury identified by pRIFLE and fluid overload greater than or equal to 10% predicted increased morbidity and mortality. Implementation of pRIFLE scoring and close monitoring of fluid overload upon admission may help develop early interventions to prevent and treat acute kidney injury in critically ill children.

Transfer effects from language processing to visual attention dynamics: The impact of orthographic transparency.

The consistency between letters and sounds varies across languages. These differences have been proposed to be associated with different reading mechanisms (lexical vs. phonological), processing grain sizes (coarse vs. fine) and attentional windows (whole words vs. individual letters). This study aimed to extend this idea to writing to dictation. For that purpose, we evaluated whether the use of different types of processing has a differential impact on local windowing attention: phonological (local) processing in a transparent language (Spanish) and lexical (global) processing of an opaque language (English). Spanish and English monolinguals (Experiment 1) and Spanish-English bilinguals (Experiment 2) performed a writing to dictation task followed by a global-local task. The first key performance showed a critical dissociation between languages: the response times (RTs) from the Spanish writing to dictation task was modulated by word length, whereas the RTs from the English writing to dictation task was modulated by word frequency and age of acquisition, as evidence that language transparency biases processing towards phonological or lexical strategies. In addition, after a Spanish task, participants more efficiently processed local information, which resulted in both the benefit of global congruent information and the reduced cost of incongruent global information. Additionally, the results showed that bilinguals adapt their attentional processing depending on the orthographic transparency.

Cognitive and contextual factors modulating grammar learning at older ages.

Second language learning has been shown more difficult for older than younger adults, however, the research trying to identify the sources of difficulty and possible modulating factors is scarce. Extrinsic (learning condition and complexity) and intrinsic factors (executive control) have been related to L2-grammar learning in younger adults. In the present study, we aim to assess whether extrinsic and intrinsic factors are also modulating grammar learning in older adults. We compared the learning performance of younger and older adults in a L2 learning task. 162 Spanish native-speakers (81 young) learnt Japañol (Japanese syntaxis and Spanish lexicon) in either an intentional (metalinguistic explanation) or an incidental (comprehension of sentences) context. The complexity of the sentences was also manipulated by introducing (or not) a subordinate clause. Individual differences in proactivity were measured with the AX-CPT task. After the learning phase, participants performed a Grammatical Judgment Task where they answered if the presented sentences were grammatically correct. No differences between older and younger adults were found. Overall, better results were found for the intentional-condition than for the incidental-condition. A significant interaction between learning context and the proactivity index in the AX-CPT task showed that more proactive participants were better when learning in the incidental-condition. These results suggest that both extrinsic and intrinsic factors are important during language learning and that they equally affect younger and older adults.

Dietary patterns in Mexican adults are associated with risk of being overweight or obese.

Our objective was to identify and describe the major dietary patterns in the Mexican adult population and their association with being overweight or obese. Dietary intake was evaluated by a FFQ that was completed by 15,890 Mexican adults who participated in the National Health and Nutrition Survey 2006. Dietary patterns were generated by cluster analysis based on the percent contribution to total energy intake from 30 food groups. We identified 3 major dietary patterns: refined foods and sweets (RS), traditional (T), and diverse (D). The T pattern was characterized by low dietary diversity, with maize and maize foods accounting for ~47% of energy intake. This pattern had the lowest contribution of most food groups, with the exception of beans (~4.0%). The RS pattern had the highest contribution of alcohol (9.4%), soft drinks (9.4%), white bread (7.7%), fast food, sweets, and snacks. The D pattern had the lowest contribution of maize (15.5%) and the highest contribution of whole-fat dairy (8.0%), rice and pasta, meat, poultry, eggs, saturated fat, fruits, and vegetables. After adjusting for age, gender, physical activity, socioeconomic status, area, and region, the RS and D dietary patterns were associated with 14 and 17% increased risk of being overweight (P < 0.01) and 20% increased risk of being obese, respectively, compared with the T dietary pattern (P < 0.001). These findings support an association of dietary patterns with being overweight or obese in a nationally representative sample of Mexican adults.

[Variables associated with mortality in a selected sample of patients older than 80 years and with some degree of functional dependence hospitalized for COVID-19 in a Geriatrics Service]. / Variables asociadas con mortalidad en una población de pacientes mayores de 80 años y con algún grado de dependencia funcional, hospitalizados por COVID-19 en un Servicio de Geriatría.

OBJECTIVE: The SARS-CoV-2 pandemic conditions high mortality rates in hospitalized elderly. Currently, a few studies include octogenarian patients and none of them analyze the impact of functional status on this health outcome. Our objective is to describe the characteristics of patients older than 80 years hospitalized for coronavirus disease 2019 (COVID-19), to determine the mortality rate and to identify associated factors. MATERIAL AND METHODS: Prospective observational study carried out on patients over 80 years admitted for COVID-19 in a Geriatrics Service. Sociodemographic, clinical, functional, mental, analytical, radiological, therapeutic and healthcare variables were collected. The factors associated with in-hospital lethality were analyzed by bivariate analysis. RESULTS: 58 cases with laboratory-confirmed COVID-19 were included, mean age 88.3 ± 5.4 years, 69% women, 65.5% moderate-severe cognitive impairment and previous Barthel index 40.66 ± 36. The main symptoms were fever (60,3%), dyspnea (53.4%) and deterioration of functional condition (50%). The most frequent comorbidities were cardiovascular disease (75.9%), hypertension (HT) (74.1%) and chronic kidney disease (CKD) (50%). A mortality rate of 41,4% was detected and the associated factors were: severe functional dependence (OR = 3.8 [1.2-12.2]), moderate-severe cognitive impairment (OR = 4.9 [1-25.4]) and CKD (OR = 3.2 [1.1-9.7]). CONCLUSION: High mortality rates are observed in older patients hospitalized for COVID-19, with a higher risk of dying in those with severe functional dependence or cognitive impairment. These findings reinforce the value of Geriatric Assessment to develop strategies to adapt diagnostic and therapeutic decision-making and to optimize care for elderly patients in the event of a new epidemic outbreak.

Energy and nutrient intake among Mexican school-aged children, Mexican National Health and Nutrition Survey 2006.

OBJECTIVE: To estimate energy, nutrient intake and diet adequacy in school-aged children based on the Mexican National Health and Nutrition Survey 2006 (ENSANUT 2006). MATERIAL AND METHODS: Food intake data from food frequency questionnaires was analyzed for 8 716 children aged 5 to 11 years. Energy and nutrients intake and adequacy were obtained. Comparisons were made at regional, urban/rural areas, socioeconomic status (SES) and nutrition status (body mass index and height/age). RESULTS: Median energy intake was 1501 kcal/d (percent adequacy: 88.0). Overweight and obesity prevalence was 25.5%. Stunting prevalence was 10%. Children at lowest SES, indigenous and from rural communities showed the highest inadequacies for vitamin A, folate, zinc, and calcium. Overweight children and those highest SES had higher risk of excessive intakes. CONCLUSIONS: Coexistence of over- and undernutrition reflects a polarized model of nutrition transition among Mexican children.

Knowledge, attitudes and practices on HIV/AIDS and prevalence of HIV in the general population of Sucre, Bolivia.

BACKGROUND: To analyse knowledge, attitudes and sexual practices on HIV/AIDS, and estimate HIV prevalence among residents of Sucre (Bolivia). METHODOLOGY: Population-based survey of residents aged 15-49 randomly selected during 2008/2009. Blood samples were collected on Whatman-filter paper and tested with enzyme-linked immunosorbent assay. Knowledge on HIV/AIDS, sexual risk practices and discriminatory attitudes against people living with HIV/AIDS (PLWHA) were modelled with multiple logistic regression. RESULTS: Of 1499 subjects, 59% were women. All subjects were HIV-negative. Inadequate knowledge of HIV/AIDS transmission and prevention was observed in 67% and risk factors varied by gender (interaction p-value<0.05). Discriminatory attitudes were displayed by 85% subjects; associated factors were: rural residence, low educational level and low income. Unsafe sex was reported by 10%; risk factors varied by residence area (interaction p-value<0.05). In urban areas, risk factors were male sex, younger age and being in common-law union. CONCLUSIONS: Prevalence of HIV infection is very low and unsafe sex is relatively uncommon. Inadequate knowledge on HIV/AIDS and discriminatory attitudes towards PLWHA are extremely high and are associated to gender, ethnic and economic inequalities.

Fluid and electrolyte disorders in the newborn: sodium and potassium.

Tubular development continues after birth in full and pre-term infants. As the survival of premature infants increases, serious imbalances in water and electrolytes in this group have become more prevalent. A diminished ability of the immature kidney to reabsorb water and respond to mineralocorticoids, a high excretion of filtered sodium, perinatal complications affecting tubular function, and the use of medications such as diuretics, indomethacin and amphotericin B, are common factors leading to sodium and potassium imbalances in this age group. Appropriate diagnosis and treatment should be guided by a careful assessment of volume status, urine electrolytes and osmolality.

Immunotherapy for Alzheimer's disease: rational basis in ongoing clinical trials.

Amyloid-ß (Aß) immunotherapy has recently begun to gain considerable attention as a potentially promising therapeutic approach to reducing the levels of Aß in the Central Nervous System (CNS) of patients with Alzheimer's Disease (AD). Despite extensive preclinical evidence showing that immunization with Aß(1-42) peptide can prevent or reverse the development of the neuropathological hallmarks of AD, in 2002, the clinical trial of AN-1792, the first trial involving an AD vaccine, was discontinued at Phase II when a subset of patients immunized with Aß(1-42) developed meningoencephalitis, thereby making it necessary to take a more refined and strategic approach towards developing novel Aß immunotherapy strategies by first constructing a safe and effective vaccine. This review describes the rational basis in modern clinical trials that have been designed to overcome the many challenges and known hurdles inherent to the search for effective AD immunotherapies. The precise delimitation of the most appropriate targets for AD vaccination remains a major point of discussion and emphasizes the need to target antigens in proteins involved in the early steps of the amyloid cascade. Other obstacles that have been clearly defined include the need to avoid unwanted anti-Aß/APP Th1 immune responses, the need to achieve adequate responses to vaccination in the elderly and the need for precise monitoring. Novel strategies have been implemented to overcome these problems including the use of N-terminal peptides as antigens, the development of DNA based epitope vaccines and vaccines based on passive immunotherapy, recruitment of patients at earlier stages with support of novel biomarkers, the use of new adjuvants, the use of foreign T cell epitopes and viral-like particles and adopting new efficacy endpoints. These strategies are currently being tested in over 10,000 patients enrolled in one of the more than 40 ongoing clinical trials, most of which are expected to report final results within two years.

Knowledge, attitudes and practices on HIV/AIDS and prevalence of HIV in the general population of Sucre, Bolivia

Background: To analyse knowledge, attitudes and sexual practices on HIV/AIDS, and estimate HIV prevalence among residents of Sucre (Bolivia).Methodology: Population-based survey of residents aged 15-49 randomly selected during 2008/2009. Blood samples were collected on Whatman-filter paper and tested with enzyme-linked immunosorbent assay. Knowledge on HIV/AIDS, sexual risk practices and discriminatory attitudes against people living with HIV/AIDS (PLWHA) were modelled with multiple logistic regression.Results: Of 1499 subjects, 59% were women. All subjects were HIV-negative. Inadequate knowledge of HIV/AIDS transmission and prevention was observed in 67% and risk factors varied by gender (interaction p-value < 0.05). Discriminatory attitudes were displayed by 85% subjects; associated factors were: rural residence, low educational level and low income. Unsafe sex was reported by 10%; risk factors varied by residence area (interaction p-value < 0.05). In urban areas, risk factors were male sex, younger age and being in common-law union.Conclusions: Prevalence of HIV infection is very low and unsafe sex is relatively uncommon. Inadequate knowledge on HIV/AIDS and discriminatory attitudes towards PLWHA are extremely high and are associated to gender, ethnic and economic inequalities.

Cryptococcosis associated with crescentic glomerulonephritis.

Crescentic glomerulonephritis (CGN) is an uncommon form of renal injury in childhood. Whereas many infectious processes are known to be linked to CGN, fungal infections typically are not. This report describes an 11-year-old girl who presented with CGN, cutaneous anergy, and cryptococcal mediastinitis. Whereas cryptococcal disease in children is usually associated with immunodeficiency (inherited or acquired), extensive immunologic evaluation of the patient was notable only for relative CD4 lymphopenia with normal CD4/CD8 ratios. Testing for human immunodeficiency virus was negative. Clinical and diagnostic studies are presented, along with a review of the literature regarding glomerular disease and cryptococcal infections.

Plasmatic level of neurosin predicts outcome of mild cognitive impairment.

BACKGROUND: Mild Cognitive Impairment (MCI) is a disorder considered to be a transitional stage from health to dementia. Diagnosis of dementias at these early stages is always troublesome because the pathophysiologic events leading to dementia precede clinical symptoms. Thus, the development of biomarkers that can be used to support the diagnosis of dementias at early stages is rapidly becoming a high priority. We have recently reported the value of measuring plasmatic levels of neurosin in the diagnosis of Alzheimer's disease (AD). The aim of this study is to determine whether measuring plasmatic concentration of neurosin is a valuable test to predict progression of MCI. METHODS: Plasmatic neurosin concentrations were measured in 68 MCI patients and 70 controls subjects. Blood samples were obtained at the beginning of the study. Sixty six patients diagnosed with MCI were observed for 18 months. In 36 patients a second blood sample was obtained at the endpoint. RESULTS: The mean value of plasmatic neurosin concentration differs significantly between MCI patients who converted to Dementia with vascular component, those who converted to AD, or those who remained at MCI stage. The relative risk of developing Dementia with vascular component when neurosin levels are higher than 5.25 ng/ml is 13 while the relative risk of developing mild AD when neurosin levels are lower than 5.25 ng/ml is 2. Increases in the levels of neurosin indicate progression to Dementia with vascular component. CONCLUSION: The measurement of plasmatic neurosin level in patients diagnosed with MCI may predict conversion from MCI to Dementia with vascular component. A single measurement is also valuable to estimate the risk of developing AD and Dementia with vascular component. Finally, repeated measurement of plasmatic neurosin might be a useful test to predict outcome in patients with MCI.

T helper cell cytokine profiles in preterm labor.

PROBLEM: To compare concentrations of T-helper cell cytokines in women with preterm labor (PTL) to normal pregnancies. METHOD OF STUDY: Fourteen women with PTL and 13 women with normal pregnancies from 24 to 34 weeks were enrolled in this pilot study. Peripheral blood mononuclear cells (PBMCs) and cervical secretions were collected. PBMCs were cultured and stimulated with mitogens. Culture supernatants and cervical secretions were assayed for type 1 (interferon-gamma, IL-12) and type 2 cytokines (IL-4, IL-5, IL-10 and IL-13) using enzyme-linked immunosorbent assays. RESULTS: There were no intergroup differences in median cytokine concentrations in PBMC cultures, or in ratios of type 1/type 2 cytokines. In cervical secretions, the median concentration of IL-4 was significantly higher in control patients. CONCLUSIONS: PTL patients appeared to have an altered T-helper cytokine balance in cervical secretions. Further study of the role of cytokines produced in the adaptive response appears warranted.

Energy and nutrient intake among Mexican school-aged children, Mexican National Health and Nutrition Survey 2006 / Consumo de energía y nutrimentos en niños mexicanos en edad escolar, Encuesta Nacional de Salud y Nutrición 2006

OBJECTIVE: To estimate energy, nutrient intake and diet adequacy in school-aged children based on the Mexican National Health and Nutrition Survey 2006 (ENSANUT 2006). MATERIAL AND METHODS: Food intake data from food frequency questionnaires was analyzed for 8 716 children aged 5 to 11 years. Energy and nutrients intake and adequacy were obtained. Comparisons were made at regional, urban/rural areas, socioeconomic status (SES) and nutrition status (body mass index and height/age). RESULTS: Median energy intake was 1501 kcal/d (percent adequacy: 88.0). Overweight and obesity prevalence was 25.5 percent. Stunting prevalence was 10 percent. Children at lowest SES, indigenous and from rural communities showed the highest inadequacies for vitamin A, folate, zinc, and calcium. Overweight children and those highest SES had higher risk of excessive intakes. CONCLUSIONS: Coexistence of over and undernutrition reflects a polarized model of nutrition transition among Mexican children.

OBJETIVO: Estimar el consumo y adecuación de energía y nutrimentos en niños escolares mexicanos que participaron en la Encuesta Nacional de Salud y Nutrición 2006 (ENSANUT 2006). MATERIAL Y MÉTODOS: Se analizaron datos de frecuencia de consumo de alimentos en 8 716 niños de entre 5 y 11 años de edad. Se calcularon la ingesta y la adecuación de energía y nutrimentos. Se hicieron comparaciones por región, área urbana/rural, nivel socioeconómico (NSE) y estado nutricio (índice de masa corporal y talla/edad). RESULTADOS: La mediana de ingestión de energía fue 1 501 kcal/día ( por ciento adecuación 88.0); 25.5 por ciento de los niños tuvieron sobrepeso u obesidad; 10 por ciento, retardo en talla. Los niños con menor NSE, los indígenas y los de comunidades rurales mostraron mayores inadecuaciones dietarias de vitamina A, folato, zinc y calcio. Los niños con sobrepeso y los de mayor NSE presentaron más riesgo de ingestiones excesivas. CONCLUSIONES: La coexistencia de malnutrición por exceso y por deficiencia evidencia una transición nutricional polarizada en niños mexicanos.

Técnicas odontológicas forenses para el reconocimiento de cadáveres, utilizadas en el Instituto de Medicina Legal durante el período del 6 de mayo al 12 de mayo de 1998 / Forensic dental techniques for the recognition of corpses, used at the Institute of Legal Medicine during the period from May 6 to May 12, 1998

¿Qué es la Odontología Forense? ¿Cuál es su utilidad en nuestro país? ¿Cuáles son las técnicas odontológicas forenses más utilizadas en El Salvador? Estas son algunas de las preguntas fundamentales que este trabajo intenta responde, a través de una investigación realizada en el Instituto de Medicina Legal "Dr. Roberto Masferrer", y con el aporte de los odontólogos forenses que trabajan en las diferentes dependencias de ese instituto, a quienes se les solicitó su colaboración para contestar una serie de preguntas referidas al tema en estudio Con los resultados de esas entrevistas, se obtuvo importante información sobre las técnicas odontológicas forenses utilizadas. Dichos resultados han sido debidamente analizados, cuantitativa y cualitativamente, para lo cual se incluyen cuadros estadísticos Toda la información recogida, como se verá en el desarrollo de esta investigación, resultó muy novedosa e interesante. V El trabajo además incluye un apartado de objetivos, limitantes, alcances y otros, así como también un extenso y completo marco teórico y una explicación detallada de la metodología que se utilizó a lo largo de esta investigación. Se espera que, con este trabajo, las personas que desean conocer aspectos relevantes sobre las técnicas odontológicas forenses, obtengan conocimientos fundamentales y de interés general en el área de la Odontología Forense.

What is Forensic Dentistry? What is its usefulness in our country? What are the most used forensic dental techniques in El Salvador? These are some of the fundamental questions that this work tries to answer, through an investigation carried out in the Institute of Legal Medicine "Dr. Roberto Masferrer", and with the contribution of forensic dentists who work in the different dependencies of that institute, Their collaboration was requested to answer a series of questions related to the subject under study. With the results of these interviews, important information was obtained on the forensic dental techniques used. These results have been duly analyzed, quantitatively and qualitatively, for which statistical tables are included. All the information collected, as will be seen in the development of this research, was very novel and interesting. V The work also includes a section on objectives, limitations, scope and others, as well as an extensive and complete theoretical framework and a detailed explanation of the methodology used throughout this research. It is expected that, with this work, people who want to know relevant aspects of forensic dental techniques, obtain fundamental knowledge of general interest in the area of ​​Forensic Dentistry.

Organización de redes para la prevención y atención de la violencia intrafamiliar / Organization of the networks for prevention and care of family violence

La presente guía constituye un contexto un instrumento útil para motivar e impulsar aquellas instituciones y organizaciones comunitarias que tienen la firme decisión de trabajar por estilos de vida no violentos y saludables en nuestras familias