Customized versus Population-Based Birth Weight References for Predicting Fetal and Neonatal Undernutrition.

OBJECTIVES: The aim of our study was to construct a model of customized birth weight curves based on a Spanish population and to compare the ability of this customized model to our population-based chart to predict a neonatal ponderal index (PI) <10th percentile. METHODS: We developed a model that can predict the 10th percentile for a fetus according to gestational age and gender as well as maternal weight, height, and age. We compared the ability of this customized model to that of our own population-based model to predict a neonatal PI <10th percentile. Data from a large database were used (32,854 live newborns, from 1993 through 2012). Only singleton pregnancies with a gestational age at delivery of 32-42 weeks were included. RESULTS: In the entire pregnant population, the customized method was superior to the population-based method for detecting newborns with a PI <10th percentile (sensitivity: 55 vs. 40.96%; specificity: 99.6 vs. 91.23%; positive predictive value: 11.49 vs. 9.55%, and negative predictive value: 98.84 vs. 98.55%, respectively). In pregnant women with a BMI >90th percentile, the sensitivity was 75%, compared to 50% in the population-based method. In pregnant women with a height >90th percentile, the sensitivity was almost as high as in the population-based method (61.53 vs. 33.33%). CONCLUSION: The customized birth weight curve is superior to the population-based method for the detection of newborns with a PI <10th percentile. This is especially the case in women in the higher scales of height and weight as well as in preterm babies.

Evaluation of an integrated system for classification, assessment and comparison of services for long-term care in Europe: the eDESDE-LTC study.

BACKGROUND: The harmonization of European health systems brings with it a need for tools to allow the standardized collection of information about medical care. A common coding system and standards for the description of services are needed to allow local data to be incorporated into evidence-informed policy, and to permit equity and mobility to be assessed. The aim of this project has been to design such a classification and a related tool for the coding of services for Long Term Care (DESDE-LTC), based on the European Service Mapping Schedule (ESMS). METHODS: The development of DESDE-LTC followed an iterative process using nominal groups in 6 European countries. 54 researchers and stakeholders in health and social services contributed to this process. In order to classify services, we use the minimal organization unit or "Basic Stable Input of Care" (BSIC), coded by its principal function or "Main Type of Care" (MTC). The evaluation of the tool included an analysis of feasibility, consistency, ontology, inter-rater reliability, Boolean Factor Analysis, and a preliminary impact analysis (screening, scoping and appraisal). RESULTS: DESDE-LTC includes an alpha-numerical coding system, a glossary and an assessment instrument for mapping and counting LTC. It shows high feasibility, consistency, inter-rater reliability and face, content and construct validity. DESDE-LTC is ontologically consistent. It is regarded by experts as useful and relevant for evidence-informed decision making. CONCLUSION: DESDE-LTC contributes to establishing a common terminology, taxonomy and coding of LTC services in a European context, and a standard procedure for data collection and international comparison.

[Typologies of people over 65 in Spain according to the European Health Survey]. / Tipologías de mayores de 65 años en España según la Encuesta Europea de Salud.

INTRODUCTION: Numerous organizations and institutions warn of the need for physical activity due to the multiple benefits it brings to the health of the population. In people over 65 years of age, doing some type of activity has a direct impact on healthy ageing. OBJECTIVE: To find out the state of health and physical activity of people over 65 years of age in Spain and to identify population typologies in order to establish specific health promotion strategies. METHOD: Descriptive cross-sectional study using a sample formed by 7167 older adults with data collected during the years 2019 and 2020 from the European Health Survey in Spain. Sociodemographic variables related to physical activity and health status were selected. A latent class analysis was carried out to analyze characteristics in subgroups of the population over 65 years of age. RESULTS: Five population subgroups were found where only one, representing 21.35% of the older adult, had a good perception of their health and regularly engaged in physical activity. CONCLUSION: Most of the Spanish population over 65 years, despite not suffering from limiting health problems, has high levels of sedentary lifestyles and obesity. It is necessary to promote healthy ageing policies taking into account the characteristics of the subgroups of the population over 65 years of age.

Impact of COVID-19 on Physical Activity and Lifestyles in Post-Confinement Sports Science Undergraduates.

The aim of this study was to assess whether the infection by SARS-CoV-2 has significantly influenced physical activity, diet, alcohol, and drug consumption habits, as well as the quality of life of students of the bachelor's degree in Physical Activity and Sports Sciences. For this purpose, an online survey was conducted, which included socio-demographic questions related to the COVID-19 disease. Physical activity was analyzed using the International Physical Activity Questionnaire (IPAQ), adherence to the Mediterranean diet using the PREDIMED questionnaire, alcohol consumption using the AUDIT questionnaire, and drug consumption using the DAST-10 questionnaire. Health-related quality of life was analyzed with the SF-12 questionnaire. Our results reveal that those who engaged in either vigorous physical activity or, on the contrary, very low-intensity physical activity, were affected by the SARS-CoV-2 disease, which reduced the average weekly time they spent on their type of activity. However, those who previously performed moderate activities have managed to stay on the same fitness level despite having suffered from SARS-CoV-2 disease (p = 0.433). In conclusion, general health is affected by suffering from the COVID-19 disease, inadequate eating habits, substance use, and the performance of vigorous or very low-intensity of physical activity.

Satisfaction Level and Performance of Physiotherapy Students in the Knowledge of Musculoskeletal Disorders through Nearpod: Preliminary Reports.

Physiotherapists are at high risk for musculoskeletal disorders. There is a need in academia to address workers' health issues at the time of graduation. Nearpod is an educational application founded on a web-based learning tool. In the field of Health Sciences, the use of Nearpod has been scarce. The objective of this study was to determine the level of satisfaction with using this interactive tool and to assess the influence of using Nearpod in class on students' performance while dealing with the topic of musculoskeletal disorders in third-year Degree in Physiotherapy students during the 2021-2022 academic year. The participants were students at the University of Cadiz. They were randomly divided into two groups, a control group using a PowerPoint presentation and an experimental group using the interactive Nearpod application. The experimental group took two surveys to determine their satisfaction with the method used. Students also took a multiple-choice test to assess the knowledge acquired. In the surveys, a high percentage of satisfaction was obtained (97.62% and 99.39%). There were no significant differences in the scores obtained by the two groups, although there were significant differences in response time in favor of the experimental group (p = 0.022). Although studies should be carried out with larger samples and on different subjects, it seems that Nearpod is a tool with great potential for teaching the study of musculoskeletal disorders.

Effectiveness of Blood Flow Restriction in Neurological Disorders: A Systematic Review.

There is scientific evidence that Blood Flow Restriction (BFR) is beneficial in healthy people, the elderly and patients with musculoskeletal disorders. A systematic review was conducted to evaluate the effectiveness of BFR in patients with neurological disorders. The literature search was conducted up until July 2022 in the following databases: PubMed, Web of Science (WOS), Physiotherapy Evidence Database (PEDro), LILACS, Scopus, Cumulative Index of Nursing and Allied Literature Complete (CINAHL), the Cochrane Library and Scientific Electronic Library Online (SciELO). The PEDro scale was used to analyze the methodological quality of the studies, and the Cochrane Collaboration's tool was employed to evaluate the risk of bias. A total of seven articles were included. BFR seems to be beneficial in neurological disorders. Improvements have been found in sensorimotor function, frequency and step length symmetry, perceived exertion, heart rate and gait speed, walking endurance, fatigue, quality of life, muscles thickness, gluteus density and muscle edema. No improvements were found in lower limb strength or balance. However, results must be taken with caution due to the small number of articles and to the large heterogeneity. More clinical trials are needed. These studies should homogenize the protocols used in larger samples, as well as improve their methodological quality.

Social inequalities in multimorbidity patterns in Europe: A multilevel latent class analysis using the European Social Survey (ESS).

Multimorbidity is associated with lower quality of life, greater disability and higher use of health services and is one of the main challenges facing governments in Europe. There is a need to identify and characterize patterns of chronic conditions and analyse their association with social determinants not only from an individual point of view but also from a collective point of view. This paper aims to respond to this knowledge gap by detecting patterns of chronic conditions and their social determinants in 19 European countries from a multilevel perspective. We used data from the ESS round 7. The final sample consisted of 18,933 individuals over 18 years of age, and patterns of multimorbidity from 14 chronic conditions were detected through Multilevel Latent Class Analysis, which also allows detecting similarities between countries. Gender, Age, Housing Location, Income Level and Educational Level were used as individual covariates to determine possible associations with social inequalities. The goodness-of-fit indices derived in a model with six multimorbidity patterns and five countries clusters. The six patterns were "Back, Digestive and Headaches", "Allergies and Respiratory", "Complex Multimorbidity", "Cancer and Cardiovascular", "Musculoskeletal" and "Cardiovascular"; the five clusters could be associated with some geographical areas or welfare states. Patterns showed significant differences in the covariates of interest, with differences in education and income being of particular interest. Some significant differences were found among patterns and the country groupings. Our findings show that chronic diseases tend to appear in a combined and interactive way, and socioeconomic differences in the occurrence of patterns are not only of the individual but also of group importance, emphasising how the welfare states in each country can influence in the health of their inhabitants.

Multimorbidity Patterns and Their Association with Social Determinants, Mental and Physical Health during the COVID-19 Pandemic.

BACKGROUND: The challenge posed by multimorbidity makes it necessary to look at new forms of prevention, a fact that has become heightened in the context of the pandemic. We designed a questionnaire to detect multimorbidity patterns in people over 50 and to associate these patterns with mental and physical health, COVID-19, and possible social inequalities. METHODS: This was an observational study conducted through a telephone interview. The sample size was 1592 individuals with multimorbidity. We use Latent Class Analysis to detect patterns and SF-12 scale to measure mental and physical quality-of-life health. We introduced the two dimensions of health and other social determinants in a multinomial regression model. RESULTS: We obtained a model with five patterns (entropy = 0.727): 'Relative Healthy', 'Cardiometabolic', 'Musculoskeletal', 'Musculoskeletal and Mental', and 'Complex Multimorbidity'. We found some differences in mental and physical health among patterns and COVID-19 diagnoses, and some social determinants were significant in the multinomial regression. CONCLUSIONS: We identified that prevention requires the location of certain inequalities associated with the multimorbidity patterns and how physical and mental health have been affected not only by the patterns but also by COVID-19. These findings may be critical in future interventions by health services and governments.

Sun Exposure during Water Sports: Do Elite Athletes Adequately Protect Their Skin against Skin Cancer?

Excessive sun exposure is the main avoidable cause of skin cancer. Outdoor sports performed without adequate photoprotection are risky practices in this respect. This study examines whether elite athletes in water sports (specifically surfing, windsurfing, and sailing) take appropriate measures to protect their skin from the sun, and whether there are differences in this respect according to age, gender, or sports discipline. This study is based on a questionnaire-based health survey. World championship competitors completed a self-administered questionnaire on their sun protection and exposure habits, as well as sunburns during the last sports season. In total, 246 participants, with an age range of 16-30 years, completed the questionnaire. Of these, 49.6% used inadequate sun protection. Those who protected their skin appropriately tended to be older than those who did not (average age = 23.28 and 20.69 years, respectively; p = 0.000). There were no significant differences in sun protection habits between male and female athletes. The rate of sunburn was very high (76.7%). A high proportion (22.5%) of participants never used sunscreen. Elite athletes in water sports are at real risk of skin lesions from overexposure to the sun, associated with inadequate photoprotection practices. Campaigns to raise awareness and to promote the early detection of skin cancer should target these risk groups.

What Sun Protection Practices Should Be Adopted by Trainee Teachers to Reduce the Risk of Skin Cancer and Other Adverse Outcomes?

Excessive sun exposure and insufficient protection are the main risk factors for the onset of melanoma and non-melanoma skin cancer (the most common types of cancer suffered by fair-skinned populations) and other adverse effects on the skin and eyes. Epidemiological data highlight the scant awareness of this risk among young people and the high rates of sunburn often recorded among this population. The main aim of the present study is to examine sun exposure and protection behavior by university students. A cross-sectional questionnaire-based study was undertaken to investigate sun exposure and protection practices among students of education sciences at a university in southern Spain. The data obtained were used to perform a descriptive, comparative analysis, by groups and by gender, of photoprotection and skin self-examination practices. The reliability and validity of the questionnaire were both tested. Of the 315 students who completed the questionnaire, 74.6% had suffered at least one sunburn during the previous year. Few made frequent use of sunscreen or protective clothing and 89.5% did not self-examine their skin. The metric properties of the questionnaire revealed its excellent reliability and validity. Among the Spanish university students considered, there was little awareness of the risk of excessive sun exposure, self-protection was insufficient, the potential exposure to dangerous levels of ultraviolet radiation was high, and most had suffered one or more sunburns in the last year. Intervention strategies should be implemented to highlight the risks involved and the need for more appropriate sun protection practices. Information campaigns should be conducted in this respect so that, when these students become teachers, they will have adequate knowledge of the risks involved and of the benefits of addressing this problem effectively, and will ultimately transfer these health education competences to their own students.

Continuous ultrafiltration during extracorporeal circulation and its effect on lactatemia: A randomized controlled trial.

INTRODUCTION: Hyperlactatemia occurs during or after extracorporeal circulation in the form of lactic acidosis, increasing the risk of postoperative complications and the mortality rate. The aim of this study was to evaluate whether continuous high-volume hemofiltration with volume replacement through a polyethersulfone filter during the extracorporeal circulation procedure decreases postoperative lactatemia and its consequences. MATERIALS AND METHODS: This was a randomized controlled trial. Patients were randomly divided into two groups of 32: with or without continuous high-volume hemofiltration through a polyethersulfone membrane. Five patients were excluded from each group during the study period. The sociodemographic characteristics, filter effects, and blood lactate levels at different times during the procedure were evaluated. Secondary endpoints were studied, such as the reduction in the intubation time and time spent in ICU. RESULTS: Lactatemia measurements performed during the preoperative and intraoperative phases were not significantly different between the two groups. However, the blood lactate levels in the postoperative period and at 24 hours in the intensive care unit showed a significant reduction and a possible clinical benefit in the hemofiltered group. Following extracorporeal circulation, the mean lactate level was higher (difference: 0.77 mmol/L; CI 0.95: 0.01-1.53) in the nonhemofiltered group than in the hemofiltered group (p<0.05). This effect was greater at 24 hours (p = 0.019) in the nonhemofiltered group (difference: 1.06 mmol/L; CI 0.95: 0.18-1.93) than in the hemofiltered group. The reduction of lactatemia is associated with a reduction of inflammatory mediators and intubation time, with an improvement in liver function. CONCLUSIONS: The use and control of continuous high-volume hemofiltration through a polyethersulfone membrane during heart-lung surgery could potencially prevent postoperative complications. The reduction of lactatemia implied a reduction in intubation time, a decrease in morbidity and mortality in the intensive care unit and a shorter hospital stay.

Factors associated with the evolution of attitudes towards mental illness in a cohort of nursing students.

WHAT IS KNOWN ON THE SUBJECT?: People with mental health difficulties have poorer physical health than the general population. The stigmatizing attitude of health professionals impacts the quality of care for these people. There is a broad background on the effectiveness of activities based on theoretical training, clinical practices or social contact to improve nursing students' attitudes towards people with mental health difficulties. There is an important need to assess whether the benefits identified in the short term are maintained in the longer term. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: The positive evolution of attitudes towards mental illness does not last over time. Some students' attitude towards people with a mental health difficulty worsened in the final stage of their training after completing clinical practices. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is necessary for tutors incorporate an understanding of stigma throughout the degree training and to discuss with the students the emotional aspects experienced during the performance of clinical practices. The design of any anti-stigma intervention must include the factor of "time". ABSTRACT: Introduction The stigma of health professionals is a contributing factor to morbi-mortality among people with mental health difficulties. There is a lack of research on long-term outcomes in nursing students. Objective To identify factors associated with the evolution of stigmatizing attitudes towards mental illness in a cohort of students trained in mental health. Method A prospective observational study of the impact of training in mental health care. Age, gender, stigma, level of previous familiarity with mental illness, self-education by Internet, academic performance and the place where practicums are conducted were evaluated on three occasions over 15 months. Results Academic performance, online consultation and the size or origin of the theoretical group were indicators of better attitudes. The positive evolution of attitudes does not last over time. Discussion Instability over time could be explained by students' experience in the practicum, although the time itself has been identified as a determining factor. Practical implications Further studies should be promoted in academia to assess the content of mental health training and its influence on the evolution of the stigmatizing attitude. It is also necessary to address stigma in small groups, where students with better academic results lead anti-stigma activities.

Photoprotection practices, knowledge and sun-related skin damage in Spanish beach handball players.

BACKGROUND: Outdoor sports are a risk activity for skin cancer, especially if adequate sun protection measures are not used. The aim of this study is to examine the photoprotection habits of outdoor (beach) handball players, and to determine the relation between duration of sports practice, photoprotection behaviour and sun-related damage to the skin. METHODS: This cross-sectional study is based on a health survey of sun exposure and protection habits and practices conducted among beach handball players in southern Spain. This survey provided data for a descriptive and comparative analysis, by groups and gender, of photoprotection and skin self-examination practices. RESULTS: Among the whole sample, 76.9% had suffered at least one sunburn event during the last year. By groups, 73.97% of the older participants (Group I, University students) and 81.25% of the younger ones (Group II, youngers players) reported this outcome, and the difference was statistically significant (p = 0.003). With respect to photoprotection, 68.5% of the players in group I and 66.7% of those in group II used sun cream with a protection factor of 30 or higher, although 52.1% of group I and 35.4% of group II did not reapply it. As concerns self-examination, 94.5% of group I and 87.5% of group II had not examined their body for skin damage during the previous year. Medical examination revealed the presence of lentigines and freckles among many players, with no significant differences between the two groups. CONCLUSIONS: Beach handball players are highly exposed to the effects of ultraviolet radiation and often take insufficient measures of sun protection. Programmes should be designed and implemented to raise awareness among adolescent and young adult sport competitors of the risks of skin cancer associated with their sports activity and to encourage them to improve their photoprotection and skin monitoring practices.

Measures of frequency used in cohorts studies to evaluate the suicidal behaviour in young people (12-26 years): A systematic review. / Medidas de frecuencia utilizadas en estudios de cohortes para evaluar el comportamiento suicida en jóvenes (12-26 años): una revisión sistemática.

INTRODUCTION: A priority for the WHO by 2020 is to have reduced the rates of suicide; they indicate difficulties in giving precise estimations due to a wide variety of factors, which include aspects related to the statistical measurements themselves of suicidal behaviour. The proportion of deaths from suicide is 8.5% among young people between 15-29 years of age. OBJECTIVE: To review the methodology used to express the frequency of suicidal behaviour in young people and to describe the methodological characteristics of the studies reviewed. METHOD: A systematic review of longitudinal studies registered on PROSPERO. The extracted information included the following: year of publication, journal, population size, sample, country, design, age, percentage of men, follow-up time and losses, suicidal behaviour, risk factors, ethical aspects, fundamentally, evaluating the measures of frequency used. RESULTS: Eighty-two articles were selected from 37,793 documents. None of the studies define the measure of frequency used for suicidal behaviour, there are currently up to 9 different ways of measuring it. The populations are students or the general population (66%), birth cohorts (16%) and specific groups. Follow-up was from 24 weeks to 30 years. Only 24.1% of the studies took ethical aspects into consideration. CONCLUSIONS: Researchers must make an effort to reach an agreement on the measures of frequency used in suicidal behaviour studies, as the methodological and terminological variability currently used impedes making any comparisons between different studies or understanding the real dimension of the problem.

A multi-level analysis of the relationship between spatial clusters of outpatient-treated depression, risk factors and mental health service planning in Catalonia (Spain).

BACKGROUND: Previous research identified high/low clusters of prevalence of outpatient-treated depression at municipal level in Catalonia (Spain). This study aims to analyse potential risk factors, both socioeconomic and related to the mental health service planning, which could influence the occurrence of hot/cold spots of depressed outpatients at two geographical levels: municipalities and service catchment areas. METHOD: Hot/cold spots were examined in relation to socioeconomic indicators at municipal level, such as population density, unemployment, university education, personal income, and also those related to service planning at catchment area level, such as adequacy of healthcare, urbanicity, accessibility and the availability of mental health community centres. The analysis has been carried out through multilevel logistic regression models in order to consider the two different scales. RESULTS: Hot spots are related to high population density, unemployment, urbanicity, the adequacy of provision of mental health services, and accessibility to mental health community centres at both study levels. On the other hand, the multilevel model weakly explains cold spots, associating them with high personal incomes. LIMITATIONS: The dependent variables of the multi-level models are binary. This limits the interpretation of the results, since they cannot provide information about the variance of the dependent variables explained by the models. CONCLUSIONS: The results described diverse risk factors at two levels which are related to a high likelihood of hot and cold spots of depression. The findings show the relevance of health planning in the distribution of diseases and the utilisation of healthcare services.

Spanish students' use of the Internet for mental health information and support seeking.

The Internet is a growing source of information for health in general, with university student being online almost daily. Evaluating their use of the Internet for mental health information and support can help understanding if online tools and websites should be used for mental health promotion and, to some extent, care. A survey was conducted with more than 600 students of Law, Nursing and Computer Science of the University of Cadiz in Spain to determine their general use of the Internet and their perceptions and trust in using this medium for mental health information. Data were collected using a 25-item-questionnaire and findings indicated that students had a strong distrust in online mental health information, notwithstanding their daily use of the Internet. The frequency and methods of their research on the Internet correlated with their health status, their medical consultations and with certain socio-demographic characteristics.

[Assessment of therapeutic passive hypothermia in newborns with hypoxic-ischemic encephalopathy that need interhospital transport]. / Valoración de la hipotermia terapéutica pasiva del recién nacido con encefalopatía hipóxico-isquémica que precisa traslado interhospitalario.

INTRODUCTION: Induced hypothermia for the first hours of life in a newborn is an effective treatment to reduce mortality and serious effects in neonates that had suffered a hypoxia episode. This method needs an universal attendance independently of the place of birth being usually necessary a transfer to the reference hospital. AIM: To analyze the efficacy of the newborn with hypoxic-ischemic encephalopathy transfer in passive hypothermia. PATIENTS AND METHODS: Descriptive study of series of cases with retrospective character of newborn from Cadiz's province that need induced hypothermia. 46 newborn were included in the study: 33 of them (71.74%) needed being transfer by the Critical Patients Transport service (CPT group), the rest (28.26%) were born into the reference hospital. RESULTS: Both groups are similar in age gestational at birth, sex, weight and hypoxic-ischemic encephalopathy degree. It analyzed variables related to hypothermia therapy and in addition in CPT group transfer specific variables. At discharge, it does not exist significant differences between groups in the efficiency-consequence of neuroprotection therapy with hypothermia (p = 0.159). It does not find complications derived from the interhospital move. CONCLUSIONS: Neonatal inter-hospital transfer in passive therapeutic hypothermia is effective, safe and necessary for the therapy compliance. It is required reach an agreement between the attendance and the reference service, setting up guides for the support and suitable range of temperature.

TITLE: Valoracion de la hipotermia terapeutica pasiva del recien nacido con encefalopatia hipoxico-isquemica que precisa traslado interhospitalario.Introduccion. La hipotermia inducida durante las primeras horas de vida del recien nacido es un tratamiento eficaz para reducir la mortalidad y secuelas graves en neonatos que han sufrido un episodio de hipoxia perinatal. Este procedimiento requiere una asistencia universalizada independiente del centro donde haya nacido, siendo necesario su traslado al hospital de referencia. Objetivo. Evaluar la eficacia del traslado interhospitalario del neonato con encefalopatia hipoxico-isquemica en hipotermia pasiva. Pacientes y metodos. Estudio descriptivo de series de casos con caracter retrospectivo. Se estudiaron neonatos de la provincia de Cadiz que precisaron hipotermia inducida. Se incluyo a un total de 46 neonatos en el analisis: 33 de ellos (71,74%) precisaron traslado por el Servicio de Traslados de Pacientes Criticos (grupo TPC); el resto (28,26%) nacio en el centro de referencia. Resultados. Ambos grupos son comparables en edad gestacional al nacimiento, sexo, peso y grado de encefalopatia hipoxico-isquemica. Se analizan variables relacionadas con la aplicacion de la hipotermia, y en el grupo TPC se analizan variables relacionadas con el traslado. No se aprecian diferencias significativas entre los grupos en la efectividad-consecuencia de la terapia neuroprotectora con hipotermia al alta hospitalaria (p = 0,159). No se encuentran complicaciones derivadas del traslado interhospitalario. Conclusiones. El traslado interhospitalario del neonato en hipotermia terapeutica realizado de forma pasiva es efectivo, seguro y necesario para el cumplimiento de la terapia. Es preciso consensuar la asistencia con el servicio de referencia, estableciendo guias en cuanto al soporte y rango de temperatura adecuada, consolidando asi una asistencia integral.