The Frequency of POCUS in the Treatment of Sepsis in the Emergency Department: A Retrospective Cohort Study.

Background: Point of care ultrasound (POCUS) is ubiquitous in the modern emergency department (ED). POCUS can be helpful in the management of patients with sepsis in many ways including determining the cause of sepsis, assessing fluid status, guiding resuscitation, and performing procedures. However, the frequency and manner in which POCUS is incorporated into the care of septic patients in community emergency medicine remains unclear. Objective: To evaluate POCUS frequency and exam types used in the care of patients with sepsis in two community EDs in Southern California. Methods: We performed a retrospective analysis of 5,264 ED visits with a diagnosis of sepsis at two community emergency departments between January 2014 and December 2018. Patients 18 years or older who were diagnosed with sepsis and had either lactate ≥ 4 mmol, a documented mean arterial pressure (MAP) < 65 mmHg, or a systolic blood pressure (SBP) < 90 mmHg were included. Charts were reviewed to determine if POCUS was used during the ED evaluation. Primary outcomes were frequency of POCUS use in the cohort, change in POCUS use over the study period, and the types of exams performed. Results: POCUS was used in 21% of encounters meeting inclusion criteria and was positively correlated with ED arrival year (OR = 1.09; CI 1.04, 1.15; p=0.001). The most common POCUS exam was ultrasound-guided central line placement, with the next most common exams being cardiac, followed by inferior vena cava (IVC). Only the frequency of cardiac, IVC, lung and Focused Assessment with Sonography in Trauma (FAST) exams were found to increase significantly over the study period. Conclusions: Total POCUS use increased significantly in this cohort of septic patients over the study period due to more cardiac, IVC, lung and FAST exams being performed.

Replicability, Robustness, and Reproducibility in Psychological Science.

Replication-an important, uncommon, and misunderstood practice-is gaining appreciation in psychology. Achieving replicability is important for making research progress. If findings are not replicable, then prediction and theory development are stifled. If findings are replicable, then interrogation of their meaning and validity can advance knowledge. Assessing replicability can be productive for generating and testing hypotheses by actively confronting current understandings to identify weaknesses and spur innovation. For psychology, the 2010s might be characterized as a decade of active confrontation. Systematic and multi-site replication projects assessed current understandings and observed surprising failures to replicate many published findings. Replication efforts highlighted sociocultural challenges such as disincentives to conduct replications and a tendency to frame replication as a personal attack rather than a healthy scientific practice, and they raised awareness that replication contributes to self-correction. Nevertheless, innovation in doing and understanding replication and its cousins, reproducibility and robustness, has positioned psychology to improve research practices and accelerate progress.

Sexual dimorphism in size and shape among populations of the lizard Sceloporus variabilis (Squamata: Phrynosomatidae).

Sexual dimorphism in lizards is determined by ecological and environmental factors. Broadly distributed species may show variation in patterns of sexual dimorphism toward either sex, as well as exhibiting variation in morphological dimensions. In the present study, sexual dimorphism in size and shape attributes was evaluated in three populations of the lizard Sceloporus variabilis from different environments in Mexico. We evaluated the size attributes of 10 morphological variables: snout-vent length (SVL), tibia length (TL), femur length (FeL), forearm length (FoL), interaxial distance (ID), head length (HL), head width (HW), head height (HH), jaw length (JL), and jaw width (JW). We also evaluated the attributes of shape (relative dimensions of the 10 morphological variables). In the size attribute, sexual dimorphism was found, with males being larger than females. In the case of shape, sexual dimorphism was found, with the females being larger in relative dimensions of ID and JW. Also, the males showed larger relative dimensions in TL, FeL and FoL. Differences were found between populations in the dimension of the variables analyzed in each sex. The pattern in size can be explained by sexual selection, where the males of each population maintain larger dimensions to compete for territory and access to females. In shape, females can be favored if they have larger relative ID and JW, as it promotes maintenance of clutch sizes, and use of microhabitats and different consumption of prey types than males. In the case of males, relative dimensions of TL, FeL and FoL may be functioning as important traits for escape from predators. The present study shows the importance of incorporating size and shape variables into analyses of sexual dimorphism among populations of a single species with a wide distribution. These types of studies help to identify the causes that promote sexual dimorphism, as well as the degree of difference among populations that inhabit different environments.

Sex Differences Among Participants in the Latin American Stroke Registry.

Background Reports on sex differences in stroke outcome and risk factors are scarce in Latin America. Our objective was to analyze clinical and prognostic differences according to sex among participants in the LASE (Latin American Stroke Registry). Methods and Results Nineteen centers across Central and South America compiled data on demographics, vascular risk factors, clinical stroke description, ancillary tests, and functional outcomes at short-term follow-up of patients included from January 2012 to January 2017. For the present study, all these variables were analyzed according to sex at hospital discharge. We included 4788 patients with a median in-hospital stay of 8 days (interquartile range, 5-8); 2677 were male (median age, 66 years) and 2111 female (median age, 60 years). Ischemic stroke occurred in 4293: 3686 as cerebral infarction (77%) and 607 as transient ischemic attack cases (12.7%); 495 patients (10.3%) corresponded to intracerebral hemorrhage. Poor functional outcome (modified Rankin scale, 3-6) was present in 1662 (34.7%) patients and 38.2% of women (P<0.001). Mortality was present in 6.8% of the registry, with 7.8% in women compared with 6.0% in men (P=0.01). Death and poor functional outcome for all-type stroke showed a higher risk in female patients (hazard ratio, 1.3, P=0.03; and hazard ratio, 1.1, P=0.001, respectively). Conclusions A worse functional outcome and higher mortality rates occurred in women compared with men in the LASE, confirming sex differences issues at short-term follow-up.

Nacidos vivos con bajo peso al nacer en Bogotá, 2014-2016 / Born alive with low weight at birth in Bogotá, 2014-2016

Introducción. La Organización Mundial de la Salud OMS considera el bajo peso al nacer como un problema de salud pública, dado que esta entidad aumenta el riesgo de padecer enfermedades no transmisibles en etapas posteriores de la vida y es la causa de morbilidad y mortalidad neonatal más frecuente. El bajo peso al nacer trae consigo deficiencia en el desarrollo físico y neurológico del neonatal, tanto a largo como a corto plazo, sea por patologías congénitas, genéticas o por eventos secundarios a la internación en unidades de cuidados intensivos neonatales, tales como infecciones asociada al cuidado de la salud, uso de ventilación asistida, consumo de determinados fármacos u otras condiciones que van sujetas a hospitalizaciones prolongadas al recién nacido. Objetivos. Medir la frecuencia de bajo peso al nacer de gestaciones a término y pretérmino e identificar los posibles factores de riesgo relacionados. Metodología. Se realizó un estudio descriptivo retrospectivo en nacimientos ocurridos en la ciudad de Bogotá entre los años 2014 a 2016, basados en datos recolectados por el Departamento Administrativo Nacional de Estadística DANE, utilizando medidas de tendencia central para evaluar la frecuencia de peso al nacer bajo. Resultados. El total de nacidos vivos en el periodo estudiado, según las estadísticas vitales del Departamento Administrativo Nacional de Estadística fue de 349.967, de los cuales 44.817 fueron nacidos vivos con bajo peso, lo que equivale al 12,80% del total de la población. El mayor registro se documentó en el año 2014 con 14.973 casos; las gestantes en las edades extremas, menores de 15 años y mayores de 44 años tienen las tasas más elevadas de bajo peso al nacer 0,18 y 0,25 respectivamente. Conclusiones. Las edades maternas extremas, resulta ser un factor riesgo para desarrollar bajo peso al nacer el intervalo de bajo peso al nacer más frecuente durante el periodo estudiado fue entre los 2.000 y 2.499 gr. El único año en el que se identificó diferencia estadística fue 2016, las edades maternas extremas presentaron las tasas más altas de nacidos vivos con bajo peso fueron en las localidades de Suba y Kennedy.

Introduction. The World Health Organization (WHO) considers low birth weight a public health problem, since it increases the risk of noncommunicable diseases in later life and is the most frequent cause of neonatal morbidity and mortality. Low birth weight brings with it a deficiency in the physical and neurological development of the neonatal, both in the long and short term, either due to congenital or genetic pathologies or due to events secondary to hospitalization in neonatal intensive care units, such as infections associated with health care, use of assisted ventilation, use of certain drugs or other conditions that are subject to prolonged hospitalization of the newborn. Objective. To measure the frequency of low birth weight in termand preterm pregnancies and to identify possible related risk factors. Methodology. A retrospective descriptive study was carried out on births that occurred in the city of Bogotá between the years 2014 and 2016, based on data collected by the National Administrative Department of Statistics (DANE), using central tendency measures to evaluate the frequency of low birth weight. Results. The total number of live births in the period studied, according to the vital statistics of the National Administrative Department of Statistics was 349.967, of which 44.817 were live births with low weight, equivalent to 12,80% of the total population. The largest record was documented in 2014 with 14.973 cases; pregnant women in the extreme ages, under 15 and over 44, have the highest rates of low birth weight 0,18 and 0,25 respectively. Conclusions. Extreme maternal ages are a risk factor for developing low birth weight. The most frequent low birth weight interval during the period studied was between 2,000 and 2,499 grams. The only year in which a statistical difference was identified was 2016, the extreme maternal ages presented the highest rates of live births with low weight were in the towns of Suba and Kennedy.

Identification and Characterization at the Single-Cell Level of Cytokine-Producing Circulating Cells in Children With Dengue.

In this study, we identified, at the single-cell level, naturally induced cytokine-producing circulating cells (CPCCs) in children with dengue virus (DENV) infection ranging clinically from mild to severe disease. Tumor necrosis factor alpha (TNF-α) and interleukin 6 (IL-6) CPCCs were detected in children with primary or secondary acute dengue virus (DENV) infection, and the pattern of these cytokines was similar to that seen in the supernatant of cultured peripheral blood mononuclear cells and partially comparable to that found in plasma. Monocytes, B cells, and myeloid dendritic cells (mDCs) were the primary CPCCs detected, and the frequency of mDCs was significantly higher in severe disease. B cells isolated from children with dengue spontaneously secreted TNF-α, IL-6, and interleukin 10, and supernatants from cultures of purified B cells induced activation of allogeneic T cells, supporting an antibody-independent function of these cells during DENV infection. Thus, CPCCs could be a new immune parameter with potential use to evaluate pathogenesis in this infection.

Medición del volumen residual en las agujas espinales tras anestesia raquídea / Measurement of residual volume in spinal needles after spinal anesthesia

ABSTRACT Introduction: Spinal anesthesia involves the administration of a dose of local anesthesia into the intrathecal space of the lumbar spine, using spinal needles with varying characteristics and design. When completing the administration of spinal anesthesia, you may check the volume of fluid remaining inside the spinal needle. Objective: To measure and compare the volume of residual fluid following the administration of spinal anesthesia using three different brands of 27 gauge spinal needles. Methods: This is an observational analytical cross-section trial for which tree types of 27 gauge commercial needles were selected: BD Whitacre pencil point, Spinocan Quincke sharp point, and Disposable spinal needle. Following the administration of spinal anesthesia, the same operator, without detaching the syringe from the needle, deposited the residual vol ume into a collection tube so that a second operator quantifies the volume using a precision micropipette. Results: The residual volume obtained fromthe27Gspinalneedlesshowed astatistically significant difference in favor of the BD Whitacre needles (P < 0.01), compared against Spinocan Quincke and Disposable spinal needle. Conclusions: The BD Whitacre pencil point proved to lodge less residual volume following spinal anesthesia. No clinical implications can be made from this finding and new studies are required to ratify these results.

R E S U M E N Introducción: La anestesia raquídea consiste en la aplicación de una dosis de anestésico local en el espacio intratecal de la columna lumbar, por medio de agujas espinales cuyas características varían tanto en calibre como en diseño. Al terminar la aplicación de una anestesia raquídea se puede comprobar un volumen remanente de líquido en el interior de la aguja espinal. Objetivo: Medir y comparar el volumen remanente de líquido posterior a la aplicación de anestesia raquídea en 3 marcas comerciales de agujas espinales de calibre 27. Métodos: Este es un estudio observacional analítico de corte transversal; se escogieron 3 tipos comerciales de agujas de calibre 27: BD Whitacre punta de lápiz, Spinocan Quincke punta cortante y Disposable spinal needle. Tras la aplicación de una anestesia raquídea, el mismo operador, sin desconectar la jeringa de la aguja, depositó el volumen residual en un tubo de recolección, para que un segundo operador cuantificara el volumen con una micropipeta de precisión. Resultados: El volumen residual obtenido de las agujas espinales 27G mostró una diferencia estadísticamente significativa a favor de las agujas BD Whitacre (p<0,01), comparadas con las agujas Spinocan Quincke y Disposable spinal needle. Conclusiones: Se comprobó que las agujas BD Whitacre pencil point alojan un menor volumen residual después de una anestesia espinal. No se puede afirmar que este hallazgo tenga implicaciones clínicas. Son necesarios nuevos estudios para corroborar estos resultados.

Interleukin-6 and neuregulin-1 as regulators of utrophin expression via the activation of NRG-1/ErbB signaling pathway in mdx cells.

Duchenne muscular dystrophy (DMD) is a neuromuscular disease originated by mutations in the dystrophin gene. A promising therapeutic approach deals with functional substitution of dystrophin by utrophin, a structural homolog that might be able to compensate dystrophin absence in DMD muscle fibers. It has been described that both interleukin-6 (IL-6) and neuregulin-1 (NRG-1; Heregulin-HRG) induce utrophin expression in skeletal muscle. We investigated a possible functional link among IL-6, NRG-1 and utrophin, in normal (C57) and dystrophic (mdx) skeletal muscle cells. Western Blot analysis allowed us to demonstrate that IL-6 (100ng/mL) induces NRG-1 receptor phosphorylation (ErbB2/ErbB3) in both cell types, in a process that depends on intracellular Ca2+ and metalloproteinase activity; it also induces a transient increase of ERK1 and GABPα phosphorylation only in dystrophic myotubes. Semiquantitative PCR showed that IL-6 treatment increases utrophin mRNA levels just in mdx myotubes. We observed that utrophin mRNA induction was abolished by BAPTA-AM (an intracellular Ca2+ chelator), GM6001 (a general metalloproteinase inhibitor), genistein (a general protein tyrosine kinase inhibitor), PD-158780 (an ErbB receptor tyrosine kinase inhibitor) and PD-98059 (a MEK inhibitor), whereas Ly-294002 and wortmannin (PI3K inhibitors) did not affect utrophin induction evoked by IL-6 in dystrophic myotubes. Our results suggest that IL-6 induces utrophin expression in mdx myotubes through activation of a NRG-1/ErbBs signaling cascade. Soluble NRG-1 elicited by proteolytic processing of transmembrane NRG-1 might induce ErbBs phosphorylation and ERK1/2 pathway activation, leading to utrophin up-regulation.

Can the behavioral sciences self-correct? A social epistemic study.

Advocates of the self-corrective thesis argue that scientific method will refute false theories and find closer approximations to the truth in the long run. I discuss a contemporary interpretation of this thesis in terms of frequentist statistics in the context of the behavioral sciences. First, I identify experimental replications and systematic aggregation of evidence (meta-analysis) as the self-corrective mechanism. Then, I present a computer simulation study of scientific communities that implement this mechanism to argue that frequentist statistics may converge upon a correct estimate or not depending on the social structure of the community that uses it. Based on this study, I argue that methodological explanations of the "replicability crisis" in psychology are limited and propose an alternative explanation in terms of biases. Finally, I conclude suggesting that scientific self-correction should be understood as an interaction effect between inference methods and social structures.

Spinal Taenia solium cysticercosis in Mexican and Indian patients: a comparison of 30-year experience in two neurological referral centers and review of literature.

OBJECTIVE: To present a retrospective study from patients with spinal cysticercosis (SC), diagnosed within the last 30 years in Mexican and Indian neurological referral centers. METHODS: This is a retrospective and comparative study of the clinical and radiological profile between Mexican and Indian patients with spinal neurocysticercosis during a 30-year period and a review of the literature during the same period. RESULTS: Twenty-seven SC patients were included: 19 from Mexico and 8 from India. SC presented predominantly with motor symptoms (21/27 patients): paraparesis and paraplegia were the most common signs; one-third of patients presented sphincter dysfunction. Imaging studies showed that parasites in vesicular stage were more frequent in patients from Mexico, while degenerative stages predominated in India. Association of subarachnoid cysticerci and hydrocephalus was observed only in Mexican patients. CONCLUSIONS: Despite the limitations of this study, the collected information supports the existence of differences in the clinical and radiological traits of SC patients between Asian and Latin-American hospitals. The possible biological factors that may underlie these differences are discussed.

Correlaciones morfológicas entre la forma de la cabeza, dieta y uso de hábitat de algunos sceloporus de México: un análisis cuantitativo / Morphological correlations between head shape, diet and habitat use of some sceloporus of Mexico: a quantitative analysis

La relación entre los caracteres morfológicos y la ecología de los organismos permite deducir respuestas adaptativas. Estas adaptaciones son el resultado de presiones selectivas que actúan sobre los organismos, así como el tipo de presa que consumen o el ambiente en el que se encuentran. De esta manera, los organismos exhiben morfologías que les permiten explotar los recursos disponibles. Sceloporus es un grupo de lagartijas altamente diverso en Norteamérica además de encontrarse en diversos hábitats, lo que lo hace un modelo óptimo para probar hipótesis adaptativas y evolutivas. El objetivo fue evaluar si existen diferencias morfológicas en la cabeza de algunas especies de Sceloporus y determinar si dicha morfología surge como una respuesta adaptativa al tipo de presa o al uso de hábitat. Para ello, se tomaron ocho variables morfométricas de la cabeza de 20 especies de éste género y que se distribuyen en México. Los datos de dieta y uso de hábitat se obtuvieron de literatura y se correlacionaron con los análsis morfológicos de este estudio. Los resultados indican una clara diferencia entre especies con respecto a cinco de ocho variables medidas, entre ellas se observó el alto de la cabeza, hocico, mandíbula, sínfisis mandibular y proceso retroarticular. Además, se obtuvo que el ancho y alto de la cabeza, se encuentran relacionados con el tipo de presa que las lagartijas consumen, y únicamente el alto de la cabeza, se correlaciona con el uso de hábitat. Con base en los resultados, se propone que la morfología de la cabeza de las lagartijas que se analizaron, está siendo moldeada por el tipo de presas que consumen y no por el ambiente, tal como se ha observado en otros lacertilios.

The relationship between morphological characters and ecology can provide adaptive responses. These adaptations are the result of selective pressures acting on organisms as well as the type of prey consumed or the environment in which they find themselves. Therefore, organisms that exhibit certain morphology traits that allow them to exploit available resources. Sceloporus is a highly diverse group of lizards in North America besides living in diverse habitats, they make an excellent model for testing adaptive and evolutionary hypotheses. The aim of this study was to assess whether there are morphological differences in the heads of some species of Sceloporus and determine whether the morphology emerges as an adaptive response to the type of prey, or habitat use. Eight morphometric variables of the head of 20 different species of this genus were found and collected throughout Mexico. Data on diet and habitat use were obtained from literature and correlated with morphological analysis of this study. The results indicate a clear difference between species for five of the eight variables measures, including top of the head, nose, jaw, mandibular symphysis and retro articular process was observed. Furthermore, it was found that the width and height of the head, is related to the type of prey lizards consumed, and only the top of the head, is correlated with habitat use. Based on these results, it is proposed that the morphology of the heads of lizards analyzed, is being shaped by the type of prey consumed, and not the environment, such as observed in other lizards.

Recurrencia histórica de peces invasores en la Reserva de la Biósfera Sierra de Huautla, México / Historical presence of invasive fish in the Biosphere Reserve Sierra de Huautla, Mexico

Historical presence of invasive fish in the Biosphere Reserve Sierra de Huautla, Mexico. The effects of invasive species on native ecosystems are varied, and these have been linked to the disappearance or decline of native fauna, changes in community structure, modification of ecosystems and as vectors of new diseases and parasites. Besides, the development of trade in species for ornamental use has contributed significantly to the import and introduction of invasive fish in some important areas for biodiversity conservation in Mexico, but the presence of these species is poorly documented. In this study we analyzed the fish community in the Biosphere Reserve Sierra de Huautla by looking at diversity changes in the last 100 years. For this, we used databases of historical records and recent collections for five sites in the Amacuzac river, along the Biosphere Reserve area. We compared the values of similarity (Jaccard index) between five times series (1898-1901, 1945-1953, 1971-1980, 1994-1995 and 2008-2009), and we obtained values of similarity (Bray-Curtis) between the five sites analyzed. In our results we recognized a total of 19 species for the area, nine non-native and ten native, three of which were eliminated for the area. Similarity values between the early days and current records were very low (.27); the major changes in the composition of the fauna occurred in the past 20 years. The values of abundance, diversity and similarity among the sampling sites, indicate the dominance of non-native species. We discuss the role of the ornamental fish trade in the region as the leading cause of invasive introduction in the ecosystem and the possible negative effects that at least four non-native species have had on native fauna and the ecosystem (Oreochromis mossambicus, Amatitlania nigrofasciata, Pterygoplichthys disjunctivus and P. pardalis). There is an urgent need of programs for registration, control and eradication of invasive species in the Sierra de Huautla Biosphere Reserve and biodiversity protection areas in Mexico. Rev. Biol. Trop. 60 (2): 669-681. Epub 2012 June 01.

Los efectos de las especies invasoras en los ecosistemas nativos son variados, y estos se han vinculado con la desaparición o disminución de la fauna nativa, cambios en la estructura de la comunidad, modificación de los ecosistemas y como vectores de nuevas enfermedades y parásitos. El desarrollo del comercio de especies para uso ornamental ha contribuido significativamente a la importación e introducción de peces invasores en algunas áreas importantes para la conservación de la biodiversidad en México, pero la presencia de estas especies está escasamente documentada. En este estudio se analiza la comunidad de peces en la reserva de Biosfera Sierra de Huautla, registrando los cambios en la diversidad en los últimos 100 años. Con bases de datos de registros históricos y recientes colecciones para cinco sitios en el río Amacuzac, que cruza la zona de reserva de la Biosfera, se comparan los valores de similitud (índice de Jaccard) entre cinco series de tiempo (1898-1901, 1945-1953, 1971-1980, 1994-1995 y 2008-2009), así mismo, obtuvimos los valores de similitud (Bray-Curtis) entre los cinco sitios analizados. En total hemos reconocido 19 especies para el área, diez nativas y nueve no nativas, de las cuales tres están extirpadas para el área, los valores de similitud entre los primeros registros y los actuales son muy bajos (0.27), los principales cambios en la composición de la fauna se han producido en los últimos 20 años. Los valores de abundancia, diversidad y similitud entre los sitios de muestreo, indican el predominio de especies no nativas. Discutimos el papel del comercio de peces ornamentales de la región como la principal causa de introducción de invasoras en el ecosistema, y los posibles efectos negativos que han tenido al menos cuatro especies en la fauna nativa y el ecosistema (Oreochromis mossambicus, Amatitlania nigrofasciata, Pterygoplichthys disjunctivus y P. pardalis), se hace notar la ausencia de programas de registro, ...

[Historical presence of invasive fish in the biosphere reserve sierra de Huautla, Mexico]. / Recurrencia histórica de peces invasores en la Reserva de la Biósfera Sierra de Huautla, México.

The effects of invasive species on native ecosystems are varied, and these have been linked to the disappearance or decline of native fauna, changes in community structure, modification of ecosystems and as vectors of new diseases and parasites. Besides, the development of trade in species for ornamental use has contributed significantly to the import and introduction of invasive fish in some important areas for biodiversity conservation in Mexico, but the presence of these species is poorly documented. In this study we analyzed the fish community in the Biosphere Reserve Sierra de Huautla by looking at diversity changes in the last 100 years. For this, we used databases of historical records and recent collections for five sites in the Amacuzac river, along the Biosphere Reserve area. We compared the values of similarity (Jaccard index) between five times series (1898-1901, 1945-1953, 1971-1980, 1994-1995 and 2008-2009), and we obtained values of similarity (Bray-Curtis) between the five sites analyzed. In our results we recognized a total of 19 species for the area, nine non-native and ten native, three of which were eliminated for the area. Similarity values between the early days and current records were very low (.27); the major changes in the composition of the fauna occurred in the past 20 years. The values of abundance, diversity and similarity among the sampling sites, indicate the dominance of non-native species. We discuss the role of the ornamental fish trade in the region as the leading cause of invasive introduction in the ecosystem and the possible negative effects that at least four non-native species have had on native fauna and the ecosystem (Oreochromis mossambicus, Amatitlania nigrofasciata, Pterygoplichthys disjunctivus and P pardalis). There is an urgent need of programs for registration, control and eradication of invasive species in the Sierra de Huautla Biosphere Reserve and biodiversity protection areas in Mexico.

Informe de la situación de salud del "Municipio de Tupiza" / Report on the health situation of the \"Municipio of Tupiza\"

De acuerdo al informe y haciendo el análisis por cada uno de las variables, se establece que se tiene un desarrollo avanzado en los determinantes de la salud, gerencia intra e intersectorialidad, participación popular, financiamiento, atención a las personas, investigación y evaluación. Las variables que tienen un desarrollo intermedio son las descentralizaciones y desconcentración, recursos humanos, sistema de información, promoción de la salud, calidad eficiencia y la atenciòn al medio

Informe de la situación de salud del "Municipio de Tupiza" / Report on the health situation of the \"Municipio of Tupiza\"

De acuerdo al informe y haciendo el análisis por cada uno de las variables, se establece que se tiene un desarrollo avanzado en los determinantes de la salud, gerencia intra e intersectorialidad, participación popular, financiamiento, atención a las personas, investigación y evaluación. Las variables que tienen un desarrollo intermedio son las descentralizaciones y desconcentración, recursos humanos, sistema de información, promoción de la salud, calidad eficiencia y la atenciòn al medio