Innovation through the Quintuple Helix in living labs: lessons learned for a transformation from lab to ecosystem.

Introduction: In the process of growing societies, and especially in the digital era we live in, there is a need for a strong push for innovation that puts citizens at the center of the process from the beginning to build more resilient, cooperative and flexible communities. Different collaborative design approaches have emerged in recent decades, one of the most interesting being Living Labs, which involves user-centered design and co-creative innovation that bring together different actors and roles. However, although these new methodologies are harnessing creativity, some aspects of this new, more ecosystemic and complex vision are not clearly understood: possible barriers, how to facilitate local and operational solutions, overcoming institutional blockage, integrating new roles, etc. Methods: The incorporation of the Quintuple Helix as a driver to ensure greater coordinated participation of local actors has proven its usefulness and impact during the re-adaptation of LifeSpace (previously named Smart House Living Lab), managed by the Polytechnic University of Madrid (Spain), a transformation based on the experiences and lessons learned during the large-scale ACTIVAGE pilot funded by the European Commission, more specifically at the Madrid Deployment Site. It involved more than 350 older adult people and other stakeholders from different areas, including family members, formal and informal caregivers, hospital service managers, third-age associations, and public service providers, forming a sense of community, which was called MAHA. Results: The living lab infrastructure evolved from a single multi-purpose environment to incorporate three harmoniously competing environments: (1) THE LAB: Headquarters for planning, demonstration, initial design phases and entry point for newcomers to the process, (2) THE CLUB: Controlled interaction environment where returning users validate solutions, focusing mainly on AHA services (MAHA CLUB), such as exergames, social interaction applications, brain training activities, etc. (3) THE NEIGHBOURHOOD: Real-life environments for free and open interaction between actors and implementation of previously validated and tested solutions. Conclusion: The Quintuple Helix model applied in LifeSpace's new vision allows a coordinated involvement of a more diverse set of actors, beyond the end-users and especially those who are not traditionally part of research and innovation processes.

Update of the Mexican College of Rheumatology Guidelines for the Pharmacological Treatment of Rheumatoid Arthritis, 2018. / Actualización de las guías del tratamiento farmacológico de la artritis reumatoide del Colegio Mexicano de Reumatología 2018.

Therapeutic advances in rheumatoid arthritis require periodic review of treatment guidelines. OBJECTIVE: To update the Mexican College of Rheumatology guidelines on the pharmacological treatment of rheumatoid arthritis. METHOD: Board certified rheumatologists from different health institutions and regions of the country participated. Work teams were formed that reviewed the previous guidelines, elaborated new questions, reviewed the literature, and scored the evidence that was presented and discussed in plenary session. The conclusions were presented to infectologists, gynaecologists and patients. Recommendations were based on levels of evidence according to GRADE methodology. RESULTS: Updated recommendations on the use of available medications for rheumatoid arthritis treatment in Mexico up to 2017 are presented. The importance of adequate and sustained control of the disease is emphasized and relevant safety aspects are described. Bioethical conflicts are included, and government action is invited to strengthen correct treatment of the disease. CONCLUSIONS: The updated recommendations of the Mexican College of Rheumatology on the pharmacological treatment of rheumatoid arthritis incorporate the best available information to be used in the Mexican health care system.

Factores asociados con bajo puntaje de Apgar en la maternidad del Centro Hospitalario Pereira Rossell / Factors associated with low Apgar score in the maternity of Pereira Rossell Hospital / Fatores associados com baixa pontuação de Apgar na maternidade do Centro Hospitalar Pereira Rossell

Introducción: La depresión neonatal es una de las causas más frecuentes de ingreso de recién nacidos a unidades especializadas de atención neonatal. La asfixia perinatal es una de las causas de bajo puntaje de Apgar, siendo uno de los criterios clínicos para su diagnóstico. Los principales factores de riesgo vinculados con bajos puntajes de Apgar pueden ser maternos (edad, patologías obstétricas, nivel socioeconómico, adicciones, etc.), del trabajo de parto y parto o, alteraciones fetales. Objetivos: Determinar los factores perinatales asociados a la baja puntuación de Apgar a los 5 minutos. Diseño: Estudio retrospectivo de casos y controles en los años 2015 y 2016. Institución: Hospital de la Mujer, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay. Participantes: Se incluyeron todos los recién nacidos término con Apgar a los 5 minutos menor o igual a 5. Resultados: Hubo un total de 12.528 nacimientos de recién nacidos vivos de término en el HM. 34 casos de recién nacidos con Apgar a los 5 minutos menor o igual a 5. Esto corresponde al 0,27% de la población. No se identificaron diferencias estadísticamente significativas en cuanto a los principales factores asociados a asfixia perinatal. Conclusiones: En el análisis de esta población, la mayoría de los factores analizados no se asocia con los casos de Apgar a los 5 minutos menor o igual a 5 (depresión neonatal moderada-severa), por lo que la mayoría de estos casos pueden no ser evitables.

Introduction: Neonatal depression is one of the most frequent causes of admission of newborns to specialized units of neonatal care. Perinatal asphyxia is one of the causes of low Apgar score, and it is one of the clinical criteria for its diagnosis. Main risk factors associated with low Apgar scores can be maternal (age, obstetric pathologies, socioeconomic level, addictions, etc.), of labor and delivery or, fetal alterations. Objective: To determine the perinatal factors associated with the low Apgar score at 5 minutes. Design: Retrospective study of cases and controls in 2015 and 2016. Institution: Maternity, Women Hospital, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay. Patients: We included all term newborns with Apgar at 5 minutes less than or equal to 5. Results: There was a total of 12,528 births of term full-term newborns in the HM. 34 cases of newborns with Apgar at 5 minutes less than or equal to 5. This corresponds to 0.27% of the population. No statistically significant differences were identified regarding the main factors associated with perinatal asphyxia. Conclusions: In the analysis of this population, most of the analyzed factors are not associated with cases of Apgar at 5 minutes less than or equal to 5 (moderate-severe neonatal depression), so that most of these cases may not be avoidable.

Introdução: A depressão neonatal é uma das causas mais freqüentes de internação de recém-nascidos em unidades especializadas de atenção neonatal. A asfixia perinatal é uma das causas do baixo índice de Apgar, sendo um dos critérios clínicos para o seu diagnóstico. Os principais fatores de risco associados aos baixos escores de Apgar podem ser maternos (idade, patologias obstétricas, nível socioeconômico, dependências, etc.), de trabalho de parto e parto, ou alterações fetais. Objetivos: Determine os fatores perinatais asociados ao baixo índice de Apgar aos 5 minutos. Design: Estudo retrospectivo de casos e controles nos anos de 2015 e 2016. Instituição: Hospital da Mulher, Centro Hospitalar Pereira Rossell, Montevidéu, Uruguai. Participantes: Todos os recém-nascidos a termo com Apgar a 5 minutos menor ou igual a 5 foram incluídos. Houve um total de 12.528 nascidos vivos a termo no MB. 34 casos de recém-nascidos com Apgar a 5 minutos menor ou igual a 5. Isso corresponde a 0,27% da população. Não foram identificadas diferenças estatisticamente significantes quanto aos principais fatores associados à asfixia perinatal. Conclusões: Na análise dessa população, a maioria dos fatores analisados não está associada aos casos de Apgar em 5 minutos menor ou igual a 5 (depressão neonatal moderada a grave), de modo que a maioria desses casos pode não ser evitável.

Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología / Clinical practice guidelines for the treatment of systemic lupus erythematosus by the Mexican College of Rheumatology

Existen varias guías de práctica clínica tanto nacionales como internacionales para el tratamiento del lupus eritematoso sistémico. No obstante, la mayoría de las guías disponibles no están diseñadas para población mexicana o solamente son para el manejo de manifestaciones específicas como nefritis lúpica o para algún estado fisiológico como el embarazo. El Colegio Mexicano de Reumatología se propuso elaborar unas guías de práctica clínica que conjuntaran la mayor parte de las manifestaciones de la enfermedad y que incluyeran adicionalmente pautas en situaciones controversiales como lo son la vacunación y el periodo perioperatorio. En el presente documento se presenta la «Guía de práctica clínica para el manejo del lupus eritematoso sistémico» propuesta por el Colegio Mexicano de Reumatología, que puede ser de utilidad principalmente a médicos no reumatólogos que se ven en la necesidad de tratar a pacientes con lupus eritematoso sistémico sin tener la formación de especialistas en reumatología. En esta guía se presentan recomendaciones sobre el manejo de manifestaciones generales, articulares, renales, cardiovasculares, pulmonares, neurológicas, hematológicas, gastrointestinales, respecto a la vacunación y al manejo perioperatorio

There are national and international clinical practice guidelines for systemic lupus erythematosus treatment. Nonetheless, most of them are not designed for the Mexican population or are devoted only to the treatment of certain disease manifestations, like lupus nephritis, or are designed for some physiological state like pregnancy. The Mexican College of Rheumatology aimed to create clinical practice guidelines that included the majority of the manifestations of systemic lupus erythematosus, and also incorporated guidelines in controversial situations like vaccination and the perioperative period. The present document introduces the «Clinical Practice Guidelines for the Treatment of Systemic Lupus Erythematosus» proposed by the Mexican College of Rheumatology, which could be useful mostly for non-rheumatologist physicians who need to treat patients with systemic lupus erythematosus without having the appropriate training in the field of rheumatology. In these guidelines, the reader will find recommendations on the management of general, articular, kidney, cardiovascular, pulmonary, neurological, hematologic and gastrointestinal manifestations, and recommendations on vaccination and treatment management during the perioperative period

Big data and machine learning in critical care: Opportunities for collaborative research.

The introduction of clinical information systems (CIS) in Intensive Care Units (ICUs) offers the possibility of storing a huge amount of machine-ready clinical data that can be used to improve patient outcomes and the allocation of resources, as well as suggest topics for randomized clinical trials. Clinicians, however, usually lack the necessary training for the analysis of large databases. In addition, there are issues referred to patient privacy and consent, and data quality. Multidisciplinary collaboration among clinicians, data engineers, machine-learning experts, statisticians, epidemiologists and other information scientists may overcome these problems. A multidisciplinary event (Critical Care Datathon) was held in Madrid (Spain) from 1 to 3 December 2017. Under the auspices of the Spanish Critical Care Society (SEMICYUC), the event was organized by the Massachusetts Institute of Technology (MIT) Critical Data Group (Cambridge, MA, USA), the Innovation Unit and Critical Care Department of San Carlos Clinic Hospital, and the Life Supporting Technologies group of Madrid Polytechnic University. After presentations referred to big data in the critical care environment, clinicians, data scientists and other health data science enthusiasts and lawyers worked in collaboration using an anonymized database (MIMIC III). Eight groups were formed to answer different clinical research questions elaborated prior to the meeting. The event produced analyses for the questions posed and outlined several future clinical research opportunities. Foundations were laid to enable future use of ICU databases in Spain, and a timeline was established for future meetings, as an example of how big data analysis tools have tremendous potential in our field.

Clinical practice guidelines for the treatment of systemic lupus erythematosus by the Mexican College of Rheumatology. / Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología.

There are national and international clinical practice guidelines for systemic lupus erythematosus treatment. Nonetheless, most of them are not designed for the Mexican population or are devoted only to the treatment of certain disease manifestations, like lupus nephritis, or are designed for some physiological state like pregnancy. The Mexican College of Rheumatology aimed to create clinical practice guidelines that included the majority of the manifestations of systemic lupus erythematosus, and also incorporated guidelines in controversial situations like vaccination and the perioperative period. The present document introduces the «Clinical Practice Guidelines for the Treatment of Systemic Lupus Erythematosus¼ proposed by the Mexican College of Rheumatology, which could be useful mostly for non-rheumatologist physicians who need to treat patients with systemic lupus erythematosus without having the appropriate training in the field of rheumatology. In these guidelines, the reader will find recommendations on the management of general, articular, kidney, cardiovascular, pulmonary, neurological, hematologic and gastrointestinal manifestations, and recommendations on vaccination and treatment management during the perioperative period.

Gout and pregnancy: A report of a new case and systematic review / Gota y embarazo: revisión sistemática, incluyendo el reporte de un nuevo caso

Abstract Article history: Received 4 January 2017 Accepted 17 October 2017 Available online 24 May 2018 Introduction: Unlike other rheumatic diseases, gout is rare in women of childbearing age. Due to the low number of cases available for the study, current information is based mainly on case reports. Objective: To describe the characteristics and the outcome of the pregnancy of women with gout. Methods: A systematic literature search was undertaken by the investigators in the PubMed and Embase databases, from the inclusion date to August 2016. Patients were included if they met the definition of gout according to the American Rheumatism Association criteria, and that they had the description of its follow-up during the pregnancy. Data collection and analysis: each pregnancy was treated as a separate observation for analysis. The maternal and fetal-neonatal outcomes data were extracted from the articles finally selected. Results: The search identified 125 potentially relevant articles, but after a full-text review only 12 articles met the inclusion criteria. Of the 23 pregnancies described, there were 16 (69.5%) live births, 5 (21.7%) were aborted, in one (4.3%), the pregnancy was terminated, and in one case report (4.3%) there was no description on the term of pregnancy. No maternal deaths were reported. Two babies died a few hours after birth. Congenital malformations were not described in any case report. The most frequent maternal complications were renal damage, anemia, preeclampsia, and postpartum uremia. Conclusions: Gout during pregnancy is not common, but it is known to occur. While the majority of women with gout delivered healthy infants, they were at increased risk of having maternal complications.

Resumen Introducción: A diferencia de otras enfermedades reumáticas, la gota es una enfermedad rara en mujeres en edad fértil. Debido al escaso número de casos disponibles para el estudio, la información actual se basa, principalmente, en reportes de casos. Objetivo: Describir las características y el desarrollo del embarazo en mujeres con gota. Métodos: Una búsqueda sistemática de literatura fue realizada en las bases de datos PubMed, Lilacs, Ebsco y Embase, desde la fecha de inclusión hasta agosto del 2016. Se incluyó a pacientes que cumplieron con la definición de gota según los criterios de la American Rheumatism Association y que tenían la descripción de su seguimiento durante el embarazo. Cada embarazo se trató como una observación independiente para el análisis. A partir de los artículos finalmente seleccionados, se extrajeron los desenlaces materno-fetales. Resultados: La búsqueda identificó 125 artículos potencialmente relevantes, después de la revisión de texto completo, 12 artículos cumplieron los criterios de inclusión. Se describen 23 embarazos que resultaron en 16 (69,5%) nacimientos vivos, 5 (21,7%) abortos, una (4,3%) interrupción del embarazo y en un caso (4,3%) no se describió el desenlace. No se reportaron muertes maternas. Dos recién nacidos fallecieron después del parto. No se documentaron malformaciones congénitas. Las complicaciones maternas más frecuentes fueron la insuficiencia renal, la anemia, la preeclampsia y la uremia posparto. Conclusiones: La gota durante el embarazo no es común, pero se sabe que ocurre. Mientras que la mayoría de las mujeres con gota tuvieron bebés sanos, presentaban un mayor riesgo de tener complicaciones maternas.

Evaluation of the activity of rheumatoid arthritis in clinical practice. Agreement between self-rated clinimetric evaluation and clinical evaluation with activity indexes: DAS28, CDAI and SDAI. / Evaluación de la actividad de la artritis reumatoide en la atención clínica habitual. Concordancia entre la autoclinimetría y la evaluación clínica con los índices de actividad: DAS28, CDAI y SDAI.

INTRODUCTION AND OBJECTIVE: To achieve control of rheumatoid arthritis (RA) it is necessary to be able to evaluate its activity. The American College of Rheumatology (ACR) recommends for this purpose indexes of activity that can be performed by the patient (PAS-II and RAPID-3) and IA including medical evaluation with laboratory studies (DAS28 and SDAI) or without them (CDAI). The objective was to analyze the concordance between self-rated clinimetric evaluation and clinimetric evaluation performed by the physician. PATIENTS AND METHOD: Analytical cross-sectional study in 126 patients with RA. The agreement was evaluated through the weighted κ coefficient and the Krippendorff's α coefficient. RESULTS: The PAS-II and RAPID-3 significantly correlated with all variables included in the core set of measures recommended by the ACR/EULAR. The agreement between PAS-II and CDAI-SDAI was good (κ: 0.6, α: 0.61-0.62), and moderate with DAS28-ESR (κ: 0.53, α: 0.56). The concordance between RAPID-3 and CDAI-SDAI was moderate (κ: 0.55-0.57, α: 0.50-0.51), and moderate with DAS28-ESR (κ: 0.55, α: 0.53). When categorizing the activity in remission/low activity vs. moderate/severe activity, the agreement was greater with the PAS-II (0.59 vs. 0.34; P=.012). CONCLUSION: The good concordance between PAS-II and SDAI supports their use in clinical practice, especially if biomarkers of inflammation or the possibility of joint count are not available. However, in order to recommend its routine application in clinical practice, it is necessary to perform longitudinal studies that assess its responsiveness.

Estenosis subglótica en granulomatosis con poliangitis (granulomatosis de Wegener): presentación de 4 casos / Subglottic stenosis in granulomatosis with polyangiitis (Wegener's granulomatosis): report of 4 cases

Introducción. La estenosis subglótica (ESG) en la granulomatosis con poliangitis (GPA) puede ser consecuencia de la enfermedad activa o de procesos inflamatorios repetitivos. Nuestro objetivo es describir las características clínicas y el tratamiento de los pacientes con ESG. Métodos. Estudio descriptivo retrospectivo de los casos diagnosticados durante el período comprendido entre el 1 de enero del 2000 y el 1 de junio del 2015. Resultados. Presentamos 4 casos; la ESG se presentó entre los 2 y 144 meses del diagnóstico de la GPA, los síntomas de presentación fueron disnea de esfuerzo y el estridor laríngeo, 3 desarrollaron ESG en ausencia de actividad sistémica. Dos sujetos con ESG grado i fueron tratados con dilatación traqueal, 2 casos presentaron reestenosis y en 3 casos fue necesario la realización de traqueostomía. Conclusión. La ESG presenta una alta morbilidad. La dilatación endoscópica proporciona alivio sintomático; sin embargo, suelen existir recidivas de la estenosis. La obstrucción grave de la vía aérea a menudo requiere de traqueostomía (AU)

Introduction. Subglottic stenosis (SGS) in granulomatosis with polyangiitis (GPA) may result from active disease or from chronic recurrent inflammation. The objective of the study was to describe the clinical features and treatment of patients with subglottic stenosis. Methods. We retrospectively reviewed the medical records of all patients with SGS due to GPA diagnosed at Rheumatology deparment between January 2000 and June 2015. Results. We present 4 cases of SGS at our department during a period of 15 years. The interval between the presentation of the GPA and SGS varied between 2 and 144 months. The leading symptoms of SGS were dyspnoea on exertion and stridor. Three patients presented SGS without evidence of systemic activity. Two patients presented SGS grade i and received tracheal dilatation; two recurred and three needed a tracheostomy due to severe airway-limiting stenosis. Conclusion. SGS presents high morbidity. Even though subglottic dilatation provides symptomatic relief, recurrences may present. Severe airway-limiting stenosis often requires tracheostomy (AU)

Subglottic stenosis in granulomatosis with polyangiitis (Wegener's granulomatosis): Report of 4 cases. / Estenosis subglótica en granulomatosis con poliangitis (granulomatosis de Wegener): presentación de 4 casos.

INTRODUCTION: Subglottic stenosis (SGS) in granulomatosis with polyangiitis (GPA) may result from active disease or from chronic recurrent inflammation. The objective of the study was to describe the clinical features and treatment of patients with subglottic stenosis. METHODS: We retrospectively reviewed the medical records of all patients with SGS due to GPA diagnosed at Rheumatology deparment between January 2000 and June 2015. RESULTS: We present 4 cases of SGS at our department during a period of 15 years. The interval between the presentation of the GPA and SGS varied between 2 and 144 months. The leading symptoms of SGS were dyspnoea on exertion and stridor. Three patients presented SGS without evidence of systemic activity. Two patients presented SGS grade i and received tracheal dilatation; two recurred and three needed a tracheostomy due to severe airway-limiting stenosis. CONCLUSION: SGS presents high morbidity. Even though subglottic dilatation provides symptomatic relief, recurrences may present. Severe airway-limiting stenosis often requires tracheostomy.

Información de las usuarias y consentimiento informado en inducciones del trabajo de parto / Information to users and informed consent in labor induction

Evaluar la información que poseen las usuarias del Centro Hospitalario Pereira Rossell (CHPR) respecto a la inducción farmacológica del trabajo de parto. Material y Métodos: Estudio transversal, prospectivo y analítico en los períodos de agosto-diciembre de 2011 y mayo-julio de 2014 en la Maternidad del Centro Hospitalario Pereira Rossell (CHPR). Se estudiaron a las usuarias sometidas a inducción del parto (n=200). Se analizó mediante un cuestionario la información que poseían sobre la inducción (objetivo, proceso y complicaciones de la misma) y se realizó concomitantemente una auditoría de historias clínicas revisando la constancia en las mismas del consentimiento informado de las usuarias previo al inicio de la inducción y la indicación detallada de la inducción del parto. Resultados: Del total de inducciones, 143 fueron con oxitocina, 32 con misoprostol y 25 con la combinación de ambos fármacos. 23% de las pacientes no conocían el objetivo de la inducción del parto; 80% desconocía el proceso de la inducción y 99% desconocía las complicaciones del mismo. En el 86% de historias, no constaba el consentimiento y en un 44% no se registró la indicación. Conclusiones: a pesar de ser la historia clínica un documento médico-legal y la inducción del parto un procedimiento no exento de complicaciones, es destacable la falta de información brindada a la paciente...

Evaluate the information held by users at Pereira Rossell Hospital about pharmacological induction of labor. Material and Methods: Cross-sectional, prospective and analytical study from August to December 2011 and from May to July 2014, in the maternity of CHPR. 200 users undergoing induction of labor were studied. Using a questionnaire, the information they had about the induction (objective, process and complications) was assessed and concomitantly an audit of medical records reviewing the records of informed consent of the patient prior to starting the induction and the detailed indications of labor induction. Results: Of all inductions, 143 were with oxytocin, 32 with misoprostol and 25 with the combination of both drugs. 23% of patients did not know the objective of labor induction; 80% did not know the process of induction and 99% did not know the complications it might have. In 86% of medical records they did not have the patient`s consent and in 44% the indication was not recorded. Conclusions: in spite of the medical history being a medical-legal document and the labor induction a procedure that may have complications, there is are remarkable lack of information provided to the patient...

Formación de médicos en postgrado de ginecología mediante entrenamiento simulado / Training of postgraduate doctors in gynecology using simulators

Presentar la primera experiencia en nuestro medio, en simulación para formación de Residentes de Ginecología de la Facultad de Medicina de Montevideo, Universidad de la República. Material y Métodos: La actividad docente se dividió en IV Módulos: I- Seguridad del Paciente y Humanismo médico, II- Anticoncepción, III- Parto instrumental y Sutura de episiotomía y IV - Emergencias obstétricas. Se realizaron exposiciones teóricas e instancias prácticas con simuladores inertes, de baja y moderada complejidad y simulación de situaciones clínicas. Se realizó autoevaluación, evaluación entre pares, aprendizaje colaborativo. Pre test y post test de conocimientos. Resultados: Los Residentes concuerdan que es una práctica muy útil y destacaron la oportunidad que la simulación brinda para practicar sin riesgo, entrenar el trabajo en equipo y actualizar guías clínicas sobre situaciones críticas. Conclusión: Ésta fue una iniciativa muy favorable para el desarrollo del área de educación médica, ya que propone una metodología de aprendizaje y de evaluación objetiva, así como un espacio para que los estudiantes puedan desarrollar destrezas y habilidades, enfrentándose con una mayor seguridad y profesionalismo al paciente...

To present the first experience with simulation for Ob/Gyn Residents in our medical community, in Montevideo School of Medicine, University of the Republic (UdeLaR). Material and Methods: The educational program was divided into 4 modules: I- Patient safety and medical humanism, II-Contraception, III- Assisted birth and episiotomy suturing and IV- Obstetric emergencies. Theoretical expositions, practical experiences with inert simulators of higher and lower complexity and simulation of clinical situations were performed.The students carried out instances of auto evaluation, peer evaluation, and collaborative learning. Also took pre- and post- tests to assess knowledge. Results: The Residents agreed in the usefulness of this practice, and highlighted the advantages simulators provide: a riskfree learning environment, an opportunity for exercising team work and updating clinical guidelines in critical conditions. Conclusion: This was a very favorable development in our medical education department, since it provided a learning and objective evaluating methodology, as well as an environment that allowed students to develop skills and abilities, and to approach patients with more professionalism and confidence...