Seroprevalence study prior and post vaccination in cancer patients in principality of Andorra (COVONCO study).

BACKGROUND: COVID-19 serologic response in patients with cancer may be lower than in the general population and may be influenced by the type of tumor or anticancer treatment. This study aims to analyze serological response prior and after vaccination of COVID-19 within the oncological population in Andorra. We set out to identify risk factors for a higher or lower serological response. PATIENTS AND METHODS: Observational, unicentric, prospective cohort study of oncologic patients in Andorra. We calculated the seroprevalence of antibodies against SARS-CoV-2 (May 2020-June 2021) and analyzed the main demographic, oncologic features and factors associated with being seropositive. RESULTS: A total of 373 patients were analyzed, mainly with solid tumours (n = 334, 89.5%). At baseline, seroprevalence was 13%, increasing during follow-up to 19%; lower seroprevalence was observed in patients with hematologic malignancies (2.6% vs 14.2%; p = 0.041) and patients receiving biological therapies (0% vs 15%, p = 0.005). In the overall seroprevalence analysis, women (23% vs 11.9%; p = 0.006) and tumour-free patients (p = 0.034) showed higher seroprevalence. The multivariable analysis showed that odds of being seropositive were higher among women (OR: 2.44, 95% CI 1.28-4.64), and patients who underwent surgery (OR: 3.35, 95% CI 1.10-10.20). About 80% of the cohort received at least one dose of COVID-19 vaccination, showing a higher seroprevalence of patients who received ChAdOx1-S than those who received BNT162b2 (24.4% vs 6.4%: p = 0.001). CONCLUSION: The seroprevalence of antibodies against SARS-COV-2 in oncologic patients in Andorra was higher among females and patients who received hormonal therapy and surgery while patients with hematologic malignancies and biologic therapies showed lower seropositivity without finding differences in the type of tumour or anticancer treatment.

Comparativa entre Screening Cognitive Impairment in Psychiatry (SCIP-S) y Minimental State Examination (MMSE) en psiquiatría forense. Estudio piloto / Comparison between Screening Cognitive Impairment in Psychiatry (SCIP-S) and Minimental State Examination (MMSE) in Forensic Psychiatry. Pilot study

Objetivos: el objetivo es comparar MMSE y SCIP-S y determinar su utilidad en la valoración del estado cognitivo en los sujetos con patología psiquiátrica en el ámbito forense.Material y métodosestudio piloto de una serie de 33 casos procedentes de los Institutos de Medicina Legal de Catalunya y Andorra, cuyo criterio de inclusión fue la existencia de una enfermedad psiquiátrica categorizada en CIE-10. En todos los casos, además de la entrevista médico forense, se administró MMSE seguido de SCIP-S.Resultadosen MMSE, 31 de los 33 entrevistados obtuvieron una puntuación directa total ≥ 24 (rendimiento cognitivo normal). En SCIP-S, solo 5 de los 33 participantes se situaron en un percentil ≥ 15 (rendimiento cognitivo normal). La diferencia entre los resultados de ambas pruebas resultó estadísticamente significativa (p < 0,05).Conclusioneseste estudio sugiere una mayor utilidad del SCIP-S frente al MMSE en la detección de déficit cognitivos en los pacientes psiquiátricos. Por tanto, se recomienda el uso del primero en la práctica médico forense. (AU)

Objectives: The objective is to compare two brief cognitive screening tests, MMSE and SCIP-S, and determine their usefulness in assessing the cognitive status of subjects diagnosed with psychiatric pathology.Material and methodsPilot study of a series of 33 cases from the Institutes of Legal Medicine of Catalonia and Andorra, whose inclusion criterion was the existence of a psychiatric pathology categorized in ICD-10. In all cases, in addition, to the forensic medical interview, MMSE was administered followed by SCIP-S.ResultsIn MMSE, 31 of the 33 interviewees obtained a total direct score ≥ 24 (normal cognitive performance). In SCIP-S, only 5 of the 33 participants were in a percentile ≥15 (normal cognitive performance). The difference between the results of both tests was statistically significant (p<0.05).ConclusionsThis study suggests a greater usefulness of SCIP-S compared to MMSE in detecting cognitive deficits in psychiatric patients. Therefore, the use of the former is recommended in forensic medical practice. (AU)

Using mobile phone data to estimate dynamic population changes and improve the understanding of a pandemic: A case study in Andorra.

Compartmental models are often used to understand and predict the progression of an infectious disease such as COVID-19. The most basic of these models consider the total population of a region to be closed. Many incorporate human mobility into their transmission dynamics, usually based on static and aggregated data. However, mobility can change dramatically during a global pandemic as seen with COVID-19, making static data unsuitable. Recently, large mobility datasets derived from mobile devices have been used, along with COVID-19 infections data, to better understand the relationship between mobility and COVID-19. However, studies to date have relied on data that represent only a fraction of their target populations, and the data from mobile devices have been used for measuring mobility within the study region, without considering changes to the population as people enter and leave the region. This work presents a unique case study in Andorra, with comprehensive datasets that include telecoms data covering 100% of mobile subscribers in the country, and results from a serology testing program that more than 90% of the population voluntarily participated in. We use the telecoms data to both measure mobility within the country and to provide a real-time census of people entering, leaving and remaining in the country. We develop multiple SEIR (compartmental) models parameterized on these metrics and show how dynamic population metrics can improve the models. We find that total daily trips did not have predictive value in the SEIR models while country entrances did. As a secondary contribution of this work, we show how Andorra's serology testing program was likely impacted by people leaving the country. Overall, this case study suggests how using mobile phone data to measure dynamic population changes could improve studies that rely on more commonly used mobility metrics and the overall understanding of a pandemic.

Diseño de un programa de prevención de Trastornos de la Conducta Alimentaria en niños / Design of a prevention program for Eating disorders in children

Introducción: En la sociedad actual, la publicidad, las redes sociales, los medios de comunicación bombardean a los usuarios con mensajes que recuerdan cuán importante es mantener una vida saludable para conseguir el cuerpo perfecto. La creciente preocupación por estilos de vida saludables, la presión social para adelgazar; la necesidad de ser aceptado y la preocupación por un ideal estético delgado asociado al éxito social, familiar y profesional podrían ser factores que explicaran esta mayor vulnerabilidad fisiológica a presentar un TCA. Este tipo de enfermedades tienen una etiología multifactorial, es por ello importante centrarnos en corregir estos factores modificables con intervenciones preventivas, tratando patrones de ideales estéticos y culturales, autoestima y autoconcepto, y prácticas dietéticas saludables. Objetivo: El presente trabajo tiene como principal objetivo disminuir la incidencia de problemas relacionados con la conducta alimentaria en los alumnos y alumnas de un centro educativo. Método: Se realizó un diseño piloto. Primero se estudió la evidencia científica existente, relacionada con los estudios de prevención y se diseñó el programa que se pondría en práctica en un grupo minoritario de alumnos de primaria. Si los resultados obtenidos son satisfactorios, el programa de prevención se extrapolará a todas las clases de sexto de primaria del centro educativo. Resultados: Los resultados exponen una idea distinta de un programa de prevención. Conclusiones: Algunos de los temas tratados en este programa son comunes en todos los programas de prevención, ya que se ha estudiado cuáles son los factores de riesgo característicos de estas enfermedades y por tanto los que hay que trabajar de forma más directa (como pueden ser autoestima y autoconcepto, habilidades sociales, términos teóricos de las enfermedades, alimentación saludable, etc) pero en esta propuesta se pretende actualizar información, y trabajar de una manera diferente.(AU)

Introduction: We live in a society where advertising, social networks, the media bombard us with messages that remind us how important it is to maintain a healthy life to achieve the perfect body. The growing concern for healthy lifestyles, social pressure to lose weight, the need to be accepted and the concern for a slim aesthetic ideal associated with social, family and professional success could be factors that explain this greater physiological vulnerability to present an ED. This type of disease has a multifactorial etiology, it is therefore important to focus on correcting these modifiable factors with preventive interventions, treating patterns of aesthetic and cultural ideals, self-esteem and self-concept, and healthy dietary practices. Aim: The main objective of this work is to reduce the incidence of problems related to eating behavior in students of an educational center. Method: The design was a pilot design. First, the existing scientific evidence related to prevention studies was studied and the program was designed, which will be put into practice in a minority group. If the results obtained are satisfactory, the prevention program will be extrapolated to all sixth grade classes of the educational center. Results: The results expose a different idea of a prevention program. Conclusions: Some of the topics covered in this program are common in all prevention programs, since it has been studied which are the characteristic risk factors of these diseases and therefore those that must be worked on more directly (such as self-esteem and self-concept, social skills, theoretical terms of diseases, healthy eating ...) but in this work proposal it is intended to update information, and in a different way.(AU)

Mobility and COVID-19 in Andorra: Country-Scale Analysis of High-Resolution Mobility Patterns and Infection Spread.

Throughout the COVID-19 pandemic, nonpharmaceutical interventions, such as mobility restrictions, have been globally adopted as critically important strategies to curb the spread of infection. However, such interventions come with immense social and economic costs and the relative effectiveness of different mobility restrictions are not well understood. Some recent works have used telecoms data sources that cover fractions of a population to understand behavioral changes and how these changes have impacted case growth. This study analyzed uniquely comprehensive datasets in order to examine the relationship between mobility and transmission of COVID-19 in the country of Andorra. The data consisted of spatio-temporal telecoms data for all mobile subscribers in the country, serology screening results for 91% of the population, and COVID-19 case reports. A comprehensive set of mobility metrics was developed using the telecoms data to indicate entrances to the country, contact with tourists, stay-at-home rates, trip-making and levels of crowding. Mobility metrics were compared to infection rates across communities and transmission rate over time. All metrics dropped sharply at the start of the country's lockdown and gradually rose again as the restrictions were gradually lifted. Several of these metrics were highly correlated with lagged transmission rate. There was a stronger correlation for measures of indoor crowding and inter-community trip-making, and a weaker correlation for total trips (including intra-community trips) and stay-at-homes rates. These findings provide support for policies which aim to discourage gathering indoors while lifting the most restrictive mobility limitations.

Outcomes After Vascular Surgery Procedures in Patients with COVID-19 Infection: A National Multicenter Cohort Study (COVID-VAS).

OBJECTIVES: To analyze the outcome of vascular procedures performed in patients with COVID-19 infection during the 2020 pandemic. METHODS: This is a multicenter, prospective observational cohort study. We analyzed data from 75 patients with COVID-19 infection undergoing vascular surgery procedures in 17 hospitals across Spain and Andorra between March and May 2020. The primary end point was 30-day mortality. Clinical Trials registry number NCT04333693. RESULTS: The mean age was 70.9 (45-94) and 58 (77.0%) patients were male. Around 70.7% had postoperative complications, 36.0% of patients experienced respiratory failure, 22.7% acute renal failure, and 22.7% acute respiratory distress syndrome (ARDS). All-cause 30-days mortality rate was 37.3%. Multivariate analysis identified age >65 years (P = 0.009), American Society of Anesthesiologists (ASA) classification IV (P = 0.004), preoperative lymphocyte count <0.6 (×109/L) (P = 0.001) and lactate dehydrogenase (LDH) >500 (UI/L) (P = 0.004), need for invasive ventilation (P = 0.043), postoperative acute renal failure (P = 0.001), ARDS (P = 0.003) and major amputation (P = 0.009) as independent variables associated with mortality. Preoperative coma (P = 0.001), quick Sepsis Related Organ Failure Assessment (qSOFA) score ≥2 (P = 0.043), lymphocytes <0.6 (×109/L) (P = 0.019) leucocytes >11.5 (×109/L) (P = 0.007) and serum ferritin >1800 mg/dL (P = 0.004), bilateral lung infiltrates on thorax computed tomography (P = 0.025), and postoperative acute renal failure (P = 0.009) increased the risk of postoperative ARDS. qSOFA score ≥2 was the only risk factor associated with postoperative sepsis (P = 0.041). CONCLUSIONS: Patients with COVID-19 infection undergoing vascular surgery procedures showed poor 30-days survival. Age >65 years, preoperative lymphocytes <0.6 (x109/L) and LDH >500 (UI/L), and postoperative acute renal failure, ARDS and need for major amputation were identified as prognostic factors of 30-days mortality.

Patient characteristics, clinical course and factors associated to ICU mortality in critically ill patients infected with SARS-CoV-2 in Spain: A prospective, cohort, multicentre study. / Características, evolución clínica y factores asociados a la mortalidad en UCI de los pacientes críticos infectados por SARS-CoV-2 en España: estudio prospectivo, de cohorte y multicéntrico.

BACKGROUND: The clinical course of COVID-19 critically ill patients, during their admission in the intensive care unit (UCI), including medical and infectious complications and support therapies, as well as their association with in-ICU mortality has not been fully reported. OBJECTIVE: This study aimed to describe clinical characteristics and clinical course of ICU COVID-19 patients, and to determine risk factors for ICU mortality of COVID-19 patients. METHODS: Prospective, multicentre, cohort study that enrolled critically ill COVID-19 patients admitted into 30 ICUs from Spain and Andorra. Consecutive patients from March 12th to May 26th, 2020 were enrolled if they had died or were discharged from ICU during the study period. Demographics, symptoms, vital signs, laboratory markers, supportive therapies, pharmacological treatments, medical and infectious complications were reported and compared between deceased and discharged patients. RESULTS: A total of 663 patients were included. Overall ICU mortality was 31% (203 patients). At ICU admission non-survivors were more hypoxemic [SpO2 with non-rebreather mask, 90 (IQR 83 to 93) vs. 91 (IQR 87 to 94); P<.001] and with higher sequential organ failure assessment score [SOFA, 7 (IQR 5 to 9) vs. 4 (IQR 3 to 7); P<.001]. Complications were more frequent in non-survivors: acute respiratory distress syndrome (ARDS) (95% vs. 89%; P=.009), acute kidney injury (AKI) (58% vs. 24%; P<10-16), shock (42% vs. 14%; P<10-13), and arrhythmias (24% vs. 11%; P<10-4). Respiratory super-infection, bloodstream infection and septic shock were higher in non-survivors (33% vs. 25%; P=.03, 33% vs. 23%; P=.01 and 15% vs. 3%, P=10-7), respectively. The multivariable regression model showed that age was associated with mortality, with every year increasing risk-of-death by 1% (95%CI: 1 to 10, P=.014). Each 5-point increase in APACHE II independently predicted mortality [OR: 1.508 (1.081, 2.104), P=.015]. Patients with AKI [OR: 2.468 (1.628, 3.741), P<10-4)], cardiac arrest [OR: 11.099 (3.389, 36.353), P=.0001], and septic shock [OR: 3.224 (1.486, 6.994), P=.002] had an increased risk-of-death. CONCLUSIONS: Older COVID-19 patients with higher APACHE II scores on admission, those who developed AKI grades ii or iii and/or septic shock during ICU stay had an increased risk-of-death. ICU mortality was 31%.

What is the protective role of perceived social support and religiosity in suicidal ideation in young adults?

Suicide is more effectively prevented when its first manifestations are detected. The first warning sign may be suicidal ideation, so identifying these thoughts and the factors that protect against them is essential if solutions are to be found to this social problem. The purpose of this study, then, is to determine the role of religiosity, perceived social support, and depressive symptomatology in the suicidal ideation of young people. We administered the following questionnaires to a sample of 409 subjects (60.64% women) between 18 and 29 years old: Brief Scale of Religiosity, Beck Depression Inventory, Scale for Suicide Ideation, and Functional Social Support Questionnaire (which includes the subscales Confidential social support and Affective social support). Participants were resident in Spain (84.60%) or Andorra (15.41%). The results show significant correlations between suicidal ideation and the two factors of perceived social support (confidential social support and affective social support). These relationships were still significant after controlling for depressive symptomatology. However, religiosity was not correlated with suicidal ideation. Therefore, the results suggest that perceived social support is a protection factor against suicidal ideas in young men and women. In fact, people who experience suicidal ideation tend to have a greater sense of dissatisfaction in relation to the social support received by such social groups as family and friends. On the other hand, the data of the present investigation suggest that religiosity has an indirect relationship with suicidal ideation in young Spanish and Andorran community populations, through its relationship with social support.

Measles and rubella elimination country profile: Andorra

Conclusions and recommendations of the European Regional Verification Commission for Measles and Rubella Elimination, based on 2018 data submitted by national verification committees.

Monitoring and managing workforce mobility in Andorra

There is no shortage of health professionals in Andorra at present. Some specialties, such as geriatric physicians, nurses and nurse assistants specialized in care of the elderly are, however, difficult to find. Furthermore, it will soon be a challenge for Andorra to cover the needs for general practitioners since most are nearing retirement age. An assessment of real needs with respect to all categories of health professional and the development of a national plan for the recruitment of health professionals are called for.

Postgraduate training in Andorra

Andorra does not have a medical school or faculty of health sciences. This means that all students wishing to pursue health-related degrees are obliged to do so in other countries. Most attend schools in nearby Catalonia (Spain) or in France, seldom in more distant countries. The Andorra Nursing School collaborates with nursing schools and teaching hospitals in Catalonia on mental-health or midwifery specialization. The country also has a vocational school, offering studies leading to assistant-nurse specialities related to working with the elderly. On obtaining degrees in these areas, students are eligible to attend the Nursing School to qualify as nurses. Andorra considers that continuing-education courses should be based on established needs, run by accredited centres and professionals, and have the potential to facilitate job and curricular incentives for health professionals.

Protective effects of tenuifolin isolated from Polygala tenuifolia Willd roots on neuronal apoptosis and learning and memory deficits in mice with Alzheimer's disease.

The roots of Polygala tenuifolia Willd have a long history of being used as a traditional Chinese medicine for the treatment of insomnia, forgetfulness, sorrow and depression. Tenuifolin (TEN) has been isolated from Polygala tenuifolia Willd roots, and this study was carried out to investigate the potential beneficial effects of TEN on neuronal apoptosis and memory deficits in a mouse model of Alzheimer's disease (AD). TEN treatment reversed spatial learning and memory deficits, as well as neuronal apoptosis in hippocampal areas, in APP/PS1 transgenic AD mice. TEN treatment protected against Aß25-35-induced apoptosis, loss of mitochondria-membrane potential, and activation of caspases-3 and -9 in SH-SY5Y cells. TEN has potential benefit in treating learning and memory deficits in APP/PS1 transgenic AD mice, and its effects may be associated with reversing AD pathology-induced neuronal apoptosis. These insights pave the way for further analysis of the potential of TEN as an AD therapeutic agent.

Experimental infection with high- and low-virulence strains of border disease virus (BDV) in Pyrenean chamois (Rupicapra p. pyrenaica) sheds light on the epidemiological diversity of the disease.

Since 2001, Pyrenean chamois (Rupicapra pyrenaica pyrenaica) populations have been affected by border disease virus (BDV) causing mortalities of more than 80% in some areas. Field studies carried out in France, Andorra, and Spain have shown different epidemiological scenarios in chamois populations. This study was designed to confirm the presence of BDV strains of a high and low virulence in free-ranging chamois populations from Pyrenees and to understand the implications of these findings to the diverse epidemiological scenarios. An experimental infection of Pyrenean chamois with a high-virulence (Cadí-6) and low-virulence (Freser-5) BDV strains was performed. Pregnant and non-pregnant animals with and without antibodies against BDV were included in each group. Cadí-6 BDV strain was confirmed to be of high virulence for seronegative adults and their foetuses. The antibody negative chamois infected with Freser-5 BDV strain did not show symptoms, presented less viral distribution and RNA load in tissues than Cadí-6 group, and cleared the virus from the serum. However, foetuses died before the end of the experiment and RNA virus was detected in sera and tissues although with lower RNA load than the Cadí-6 group. Chamois from both groups presented lesions in brain but the ones infected with the low-virulence Freser-5 BDV strain were mild and most likely transient. In both groups, seropositive pregnant females and all but one of their foetuses did not present viraemia or viral RNA in tissues. The existence of a low-virulence strain has been confirmed experimentally and related to chamois population infection dynamics in the area where it was isolated. Such strain may persist in the chamois population through PI animals and may induce cross-protection in chamois against high-virulence strains. This study demonstrates that viral strain diversity is a significant factor in the heterogeneity of epidemiological scenarios in Pyrenean chamois populations.

Routine immunization profile: Andorra

Summary of routine immunization and vaccine-preventable diseases surveillance data, based primarily on data for 2017 submitted through the WHO/UNICEF Joint Reporting Form on Immunization.

Measles and rubella elimination country profile: Andorra

Conclusions and recommendations of the European Regional Verification Commission for Measles and Rubella Elimination, based on 2017 data submitted by national verification committees

Participatory approaches to reaching the Sustainable Development Goals: Andorra: national strategy on nutrition, sport and health: engaging the general public

In 2016, Andorra carried out its second national nutrition survey to evaluate the impact of a decade of action to promote healthy eating habits and regular physical activity in the population. This action was linked to implementation of the National strategy on nutrition, sport and health. The survey assessed food consumption, physical activity and other health-related habits, as well as anthropometric trends in the adult population. Comparing the results of the second national nutrition survey with those of the first survey has provided information that will be useful in reviewing and updating health-promotion policies and programmes related to healthy lifestyles in Andorra, as well as in decision-making in this area. Andorra’s efforts in the area of nutrition span across several United Nations Sustainable Development Goals (SDGs): SDG 2 (zero hunger), specifically targets 2.1, 2.2, and 2.4 to ensure access for all people to sufficient food, end all forms of malnutrition, and implement resilient agriculture practices that help to maintain ecosystems, respectively; SDG 3 (good heath and well-being), specifically targets 3.4 and 3.5 related to premature mortality from noncommunicable diseases and the prevention and treatment of harmful use of alcohol; SDG 4 (quality education), specifically target 4.7 on education for sustainable lifestyles; and SDG 10 (reduced inequalities). They also address several of the interdependent strategic directions of the WHO Roadmap to implement the 2030 Agenda for Sustainable Development, building on Health 2020, the European policy for health and well-being, namely, preventing disease and addressing health determinants by promoting multi- and intersectoral policies throughout the life-course, and establishing healthy places, settings and resilient communities.

[The design of a population register on cerebral palsy: its application and analysis in Andorra and Navarre]. / Diseño de un registro de paralisis cerebral de ambito poblacional: aplicacion y analisis en Andorra y Navarra.

INTRODUCTION: Cerebral palsy describes a group of developmental and posture disorders, which cause a limitation of activity due to non-progressive damage occurring in the developing brain. A population register facilitates the identification of cerebral palsy cases within a specific geographic population. Its usefulness is recognized in the world literature but in Spain, published databases focus on the treatment or complications of cerebral palsy. AIMS: To propose a population register that can be useful in different areas of our environment and to evaluate its validity through its application in two differentiated and geographically delimited health areas. SUBJECTS AND METHODS: The registry consists of 124 items divided into seven sections: data on the child filiations, maternal history and parents' information, pregnancy and neonatal period data, diagnoses and classification, neuroimaging tests, therapeutic interventions and others. Patients attended in external consultations in Navarre and Andorra were included. RESULTS: In the register, 53 patients (52.8% females) were evaluated. 56.5% were premature. Spastic cerebral palsy is the most frequent presentation. 42% have associated epilepsy. CONCLUSIONS: The use of population registers allows a better knowledge of cerebral palsy as well as the evaluation and development of prevention strategies and optimization of care resources with objective data. It is necessary to generalize the use of this type of records in our environment.

TITLE: Diseño de un registro de paralisis cerebral de ambito poblacional: aplicacion y analisis en Andorra y Navarra.Introduccion. La paralisis cerebral describe un grupo de trastornos del desarrollo y la postura que causan una limitacion de la actividad debido a alteraciones no progresivas ocurridas en el cerebro en desarrollo. El registro poblacional facilita la identificacion de los casos de paralisis cerebral dentro de una poblacion geografica especifica. Esta reconocida su utilidad en la bibliografia, pero en España, las bases de datos publicadas se centran en el tratamiento o las complicaciones de la paralisis cerebral. Objetivos. Proponer un registro poblacional que pueda ser util en diferentes areas de nuestro entorno y evaluar su validez mediante su aplicacion en dos areas de salud diferenciadas y geograficamente delimitadas. Sujetos y metodos. El registro elaborado constaba de 124 items divididos en siete apartados: datos de filiacion del niño, historia materna e informacion de los padres, datos del embarazo y periodo neonatal, diagnosticos y clasificacion, pruebas de neuroimagen, intervenciones terapeuticas y otros. Se incluyo a los pacientes atendidos en consultas externas en Navarra y Andorra. Resultados. En el registro se evaluo a 53 pacientes (52,8% mujeres). El 56,5% fueron prematuros. La paralisis cerebral espastica es la presentacion mas frecuente. Un 42% asociaba epilepsia. Conclusiones. El uso de registros poblacionales permite un mejor conocimiento de la paralisis cerebral, asi como la evaluacion y el desarrollo de estrategias de prevencion y optimizacion de los recursos asistenciales con datos objetivos. Es necesaria la generalizacion del uso de este tipo de registros en nuestro entorno.