MAPK/MAK/MRK overlapping kinase (MOK) controls microglial inflammatory/type-I IFN responses via Brd4 and is involved in ALS.

Amyotrophic lateral sclerosis (ALS) is a fatal and incurable neurodegenerative disease affecting motor neurons and characterized by microglia-mediated neurotoxic inflammation whose underlying mechanisms remain incompletely understood. In this work, we reveal that MAPK/MAK/MRK overlapping kinase (MOK), with an unknown physiological substrate, displays an immune function by controlling inflammatory and type-I interferon (IFN) responses in microglia which are detrimental to primary motor neurons. Moreover, we uncover the epigenetic reader bromodomain-containing protein 4 (Brd4) as an effector protein regulated by MOK, by promoting Ser492-phospho-Brd4 levels. We further demonstrate that MOK regulates Brd4 functions by supporting its binding to cytokine gene promoters, therefore enabling innate immune responses. Remarkably, we show that MOK levels are increased in the ALS spinal cord, particularly in microglial cells, and that administration of a chemical MOK inhibitor to ALS model mice can modulate Ser492-phospho-Brd4 levels, suppress microglial activation, and modify the disease course, indicating a pathophysiological role of MOK kinase in ALS and neuroinflammation.

SARS-CoV-2 E protein interacts with BRD2 and BRD4 SEED domains and alters transcription in a different way than BET inhibition.

Bromodomain and extra-terminal (BET) proteins are relevant chromatin adaptors involved in the transcriptional control of thousands of genes. Two tandem N-terminal bromodomains are essential for chromatin attachment through acetyl-histone recognition. Recently, the BET proteins members BRD2 and BRD4 were found to interact with the SARS-CoV-2 envelope (E) protein, raising the question of whether the interaction constitutes a virus hijacking mechanism for transcription alteration in the host cell. To shed light on this question, we have compared the transcriptome of cells overexpressing E with that of cells treated with the BET inhibitor JQ1. Notably, E overexpression leads to a strong upregulation of natural immunity- and interferon response-related genes. However, BET inhibition results in the downregulation of most of these genes, indicating that these two conditions, far from causing a significant overlap of the altered transcriptomes, course with quite different outputs. Concerning the interaction of E protein with BET members, and differing from previous reports indicating that it occurs through BET bromodomains, we find that it relies on SEED and SEED-like domains, BET regions rich in Ser, Asp, and Glu residues. By taking advantage of this specific interaction, we have been able to direct selective degradation of E protein through a PROTAC system involving a dTAG-SEED fusion, highlighting the possible therapeutic use of this peptide for targeted degradation of a viral essential protein.

SUMO control of nervous system development.

In the last decades, the post-translational modification system by covalent attachment of the SUMO polypeptide to proteins has emerged as an essential mechanism controlling virtually all the physiological processes in the eukaryotic cell. This includes vertebrate development. In the nervous system, SUMO plays crucial roles in synapse establishment and it has also been linked to a variety of neurodegenerative diseases. However, to date, the involvement of the modification of specific targets in key aspects of nervous system development, like patterning and differentiation, has remained largely elusive. A number of recent works confirm the participation of target-specific SUMO modification in critical aspects of nervous system development. Here, we review pioneering and new findings demonstrating the essential role SUMO plays in neurogenesis and other facets of neurodevelopment, which will help to precisely understand the variety of mechanisms SUMO utilizes to control most fundamental processes in the cell.

Structural diversification of vitamin D using microbial biotransformations.

Vitamin D deficiencies are linked to multiple human diseases. Optimizing its synthesis, physicochemical properties, and delivery systems while minimizing side effects is of clinical relevance and is of great medical and industrial interest. Biotechnological techniques may render new modified forms of vitamin D that may exhibit improved absorption, stability, or targeted physiological effects. Novel modified vitamin D derivatives hold promise for developing future therapeutic approaches and addressing specific health concerns related to vitamin D deficiency or impaired metabolism, such as avoiding hypercalcemic effects. Identifying and engineering key enzymes and biosynthetic pathways involved, as well as developing efficient cultures, are therefore of outmost importance and subject of intense research. Moreover, we elaborate on the critical role that microbial bioconversions might play in the a la carte design, synthesis, and production of novel, more efficient, and safer forms of vitamin D and its analogs. In summary, the novelty of this work resides in the detailed description of the physiological, medical, biochemical, and epidemiological aspects of vitamin D supplementation and the steps towards the enhanced and simplified industrial production of this family of bioactives relying on microbial enzymes. KEY POINTS: • Liver or kidney pathologies may hamper vitamin D biosynthesis • Actinomycetes are able to carry out 1α- or 25-hydroxylation on vitamin D precursors.

Exome sequencing links the SUMO protease SENP7 with fatal arthrogryposis multiplex congenita, early respiratory failure and neutropenia.

BACKGROUND: SUMOylation involves the attachment of small ubiquitin-like modifier (SUMO) proteins to specific lysine residues on thousands of substrates with target-specific effects on protein function. Sentrin-specific proteases (SENPs) are proteins involved in the maturation and deconjugation of SUMO. Specifically, SENP7 is responsible for processing polySUMO chains on targeted substrates including the heterochromatin protein 1α (HP1α). METHODS: We performed exome sequencing and segregation studies in a family with several infants presenting with an unidentified syndrome. RNA and protein expression studies were performed in fibroblasts available from one subject. RESULTS: We identified a kindred with four affected subjects presenting with a spectrum of findings including congenital arthrogryposis, no achievement of developmental milestones, early respiratory failure, neutropenia and recurrent infections. All died within four months after birth. Exome sequencing identified a homozygous stop gain variant in SENP7 c.1474C>T; p.(Gln492*) as the probable aetiology. The proband's fibroblasts demonstrated decreased mRNA expression. Protein expression studies showed significant protein dysregulation in total cell lysates and in the chromatin fraction. We found that HP1α levels as well as different histones and H3K9me3 were reduced in patient fibroblasts. These results support previous studies showing interaction between SENP7 and HP1α, and suggest loss of SENP7 leads to reduced heterochromatin condensation and subsequent aberrant gene expression. CONCLUSION: Our results suggest a critical role for SENP7 in nervous system development, haematopoiesis and immune function in humans.

Synthesis and interaction with growth factors of sulfated oligosaccharides containing an anomeric fluorinated tail.

Compounds that mimic the biological properties of glycosaminoglycans (GAGs) and can be more easily prepared than the native GAG oligosaccharides are highly demanded. Here, we present the synthesis of sulfated oligosaccharides displaying a perfluorinated aliphatic tag at the reducing end as GAG mimetics. The preparation of these molecules was greatly facilitated by the presence of the fluorinated tail since the reaction intermediates were isolated by simple fluorous solid-phase extraction. Fluorescence polarization competition assays indicated that the synthesized oligosaccharides interacted with two heparin-binding growth factors, midkine (MK) and FGF-2, showing higher binding affinities than the natural oligosaccharides, and can be therefore considered as useful GAG mimetics. Moreover, NMR experiments showed that the 3D structure of these compounds is similar to that of the native sequences, in terms of sugar ring and glycosidic linkage conformations. Finally, we also demonstrated that these derivatives are able to block the MK-stimulating effect on NIH3T3 cells growth.

Effectiveness and safety of tildrakizumab for the treatment of psoriasis in real-world settings at 24 weeks: A retrospective, observational, multicentre study by the Spanish Psoriasis Group.

BACKGROUND: Tildrakizumab is a humanized, IgG1/κ antibody that interacts with the p19 subunit of interleukin 23. It is approved for the treatment of moderate-to-severe plaque psoriasis. Real-world evidence on the effectiveness and safety of tildrakizumab is limited. OBJECTIVES: To assess the effectiveness and safety of tildrakizumab at 24 weeks in patients with moderate-to-severe plaque psoriasis in routine clinical practice. METHODS: Retrospective, observational, multicentre study including adult patients with moderate-to-severe plaque psoriasis treated with tildrakizumab under real-life conditions. Patient data were extracted from anonymized electronic medical records. Statistical analysis was performed using SPSS22. RESULTS: A total of 190 patients were included. About 53.9% were men with a mean age of 51.45 (SD 3.9) and a mean BMI of 29.13 (SD 6.21). About 79.8% (132 out of 190) of patients had previously received biological therapy (BT) and 17.3% (33 out of 191) had psoriatic arthritis. Baseline PASI was 10.7 (SD 6.53). Up to 109 patients reached Week 24 and at this point mean baseline PASI decreased to 1.7 (SD 4.8), representing an 88.79% mean PASI reduction. At 6 months, 87.1% and 40.3% of the treated patients achieved PASI ≤3 and ≤1, respectively. At Week 24 mean BSA decreased from 13.2 (SD 10.07) to 1.6 (SD 4.40) and mean DLQI went from 12.5 (SD 7.12) to 1.2 (SD 3.27). Multivariate analysis showed no differences when effectiveness was correlated with gender, obesity, psoriatic arthritis or prior exposure to BT. The rate of adverse events (AE) was 5.9% (11 out of 190), where infections were the most frequent AE (4 out of 11). One patient suffered a haemorrhagic ictus and one patient died due to causes unrelated to the study. CONCLUSION: Tildrakizumab was effective and safe in a large cohort of patients with moderate-to-severe plaque psoriasis treated in a routine clinical setting.

Barriers to achieving quality birth care under the Sentinel Care model in Mexico.

OBJECTIVE: To explore the use of birth care in a Sentinel Unit. MATERIALS AND METHODS: We interviewed eight health providers and 12 female users of health services to explore the main reasons to use birth care in a Sentinel Unit. RESULTS: Findings indicate that the reasons for which health providers do not attend births were fear of legal claims by users, lack of institutional support if complications arise, lack of training, not feeling confident in obstetric care, and the lack of necessary supplies. Female users mentioned the perception of a lack of trained physicians and a lack of necessary materials and medicines. CONCLUSIONS: Despite the strengthening of the infrastructure and human resources, as well as a 24/365 model attention and the increase of health personnel in the sentinel units, there are still significant barriers in certain units to achieve compliance with coverage of quality obstetric care focused on the needs of women.

Políticas nacionales para el control del VIH y la evolución de la epidemia en México: un análisis de 1990 a 2017.

OBJETIVO: Analizar los cambios en la carga de la enfermedad del VIH de 1990-2017 y la influencia de las políticas y programas implementadas para su prevención y control. Material y métodos. Se elaboró una línea de tiempo de políticas e intervenciones en México; mediante modelos de regresión JoinPoint, se analizó su relación con los cambios ocurridos en las tendencias de la carga de la enfermedad del VIH. RESULTADOS: Los cambios en la carga de enfermedad se relacionan con la universalización del acceso a los medicamentos antirretrovirales (ARV), programas de atención integral y el combate al estigma y la discriminación. En el periodo analizado se observa descenso de la mortalidad relacionado con el acceso universal y gratuito a los ARV. La magnitud de los cambios tiende a ser mayor en los hombres que en las mujeres. CONCLUSIONES: Las políticas y programas implementados para tratar a las personas con VIH/Sida en México se integraron en estrategias cada vez más cohesionadas y eficaces.

Design and implementation of AMBAR: an innovative evidence-based training program for childbirth and newborn care.

OBJECTIVE: To present the development of a training model called AMBAR (Atención a la mujer embarazada y al recién nacido [Care for pregnant women and newborns]), which was designed to improve the quality of attention of health personnel responsible for obstetric care. MATERIALS AND METHODS: AMBAR was designed based on the results of a qualitative study exploring public health providers' needs and experiences. It was implemented in three health networks, and a total of 339 health personnel participated. RESULTS: The educational design of the course was appealing to the trained personnel, and the inclusion of simulations in all modules encouraged interest, participation, as well as the integration of new knowledge and skills into practice. CONCLUSION: AMBAR can promote better practices and increase the quality of birth care. With the proper support and willingness of staff and management, AMBAR can be implemented in all health services, both public and private.

Tectomer-Mediated Optical Nanosensors for Tyramine Determination.

The development of optical sensors for in situ testing has become of great interest in the rapid diagnostics industry. We report here the development of simple, low-cost optical nanosensors for the semi-quantitative detection or naked-eye detection of tyramine (a biogenic amine whose production is commonly associated with food spoilage) when coupled to Au(III)/tectomer films deposited on polylactic acid (PLA) supports. Tectomers are two-dimensional oligoglycine self-assemblies, whose terminal amino groups enable both the immobilization of Au(III) and its adhesion to PLA. Upon exposure to tyramine, a non-enzymatic redox reaction takes place in which Au(III) in the tectomer matrix is reduced by tyramine to gold nanoparticles, whose reddish-purple color depends on the tyramine concentration and can be identified by measuring the RGB coordinates (Red-Green-Blue coordinates) using a smartphone color recognition app. Moreover, a more accurate quantification of tyramine in the range from 0.048 to 10 µM could be performed by measuring the reflectance of the sensing layers and the absorbance of the characteristic 550 nm plasmon band of the gold nanoparticles. The relative standard deviation (RSD) of the method was 4.2% (n = 5) with a limit of detection (LOD) of 0.014 µM. A remarkable selectivity was achieved for tyramine detection in the presence of other biogenic amines, especially histamine. This methodology, based on the optical properties of Au(III)/tectomer hybrid coatings, is promising for its application in food quality control and smart food packaging.

How to deal with the suffering: Utility of an emotional containment strategy to collect data for verbal autopsies in Mexico.

Verbal autopsies are often used to establish cause of death but can be emotionally taxing on the interviewers. We conducted focus groups with interviewers (N = 15) who collected data for verbal autopsies in Mexico in order to explore the utility of an emotional containment strategy designed to boost self-confidence and resilience. The interviewers reflected on broader cultural perspectives on illness and death and described the strategy as helpful in developing strategies to manage emotionally stressful situations and develop their confidence in their work performance. This type of intervention may be useful for field personnel who perform verbal autopsy interviews.KEY MESSAGESIn low- and middle-income countries with less reliable statistics systems, a significant proportion of deaths is not certified by a professional doctor. This complicates the registration of causes of death, which is a crucial issue for health systems. In the absence of reliable vital statistics systems, verbal autopsies (VA) offer an alternative for establishing cause of death.In response to emotional crises leading to resignations among the interviewers while testing an instrument for collecting VA, we designed an emotional containment strategy (ECS). It was specifically crafted to boost the self-confidence and resilience of participants in addition to enhancing their capacity for emotional recovery and to regain a functional state. In order to explore ECS results we conducted a qualitative cross-sectional study with four focus groups of interviewers who collected VA.The results obtained were positive, the interviewers were able to perform their work better by overcoming the emotional crisis that occurred both in them and in the people they interviewed.We recommend developing this type of intervention with all field staff performing verbal autopsy interviews, not only as a resource for emotional health, but also as a means of achieving better-quality data collection.

Cancer-Associated Dysregulation of Sumo Regulators: Proteases and Ligases.

SUMOylation is a post-translational modification that has emerged in recent decades as a mechanism involved in controlling diverse physiological processes and that is essential in vertebrates. The SUMO pathway is regulated by several enzymes, proteases and ligases being the main actors involved in the control of sumoylation of specific targets. Dysregulation of the expression, localization and function of these enzymes produces physiological changes that can lead to the appearance of different types of cancer, depending on the enzymes and target proteins involved. Among the most studied proteases and ligases, those of the SENP and PIAS families stand out, respectively. While the proteases involved in this pathway have specific SUMO activity, the ligases may have additional functions unrelated to sumoylation, which makes it more difficult to study their SUMO-associated role in cancer process. In this review we update the knowledge and advances in relation to the impact of dysregulation of SUMO proteases and ligases in cancer initiation and progression.

Midkine Interaction with Chondroitin Sulfate Model Synthetic Tetrasaccharides and Their Mimetics: The Role of Aromatic Interactions.

Midkine (MK) is a neurotrophic factor that participates in the embryonic central nervous system (CNS) development and neural stem cell regulation, interacting with sulfated glycosaminoglycans (GAGs). Chondroitin sulfate (CS) is the natural ligand in the CNS. In this work, we describe the interactions between a library of synthetic models of CS-types and mimics. We did a structural study of this library by NMR and MD (Molecular Dynamics), concluding that the basic shape is controlled by similar geometry of the glycosidic linkages. Their 3D structures are a helix with four residues per turn, almost linear. We have studied the tetrasaccharide-midkine complexes by ligand observed NMR techniques and concluded that the shape of the ligands does not change upon binding. The ligand orientation into the complex is very variable. It is placed inside the central cavity of MK formed by the two structured beta-sheets domains linked by an intrinsically disordered region (IDR). Docking analysis confirmed the participation of aromatics residues from MK completed with electrostatic interactions. Finally, we test the biological activity by increasing the MK expression using CS tetrasaccharides and their capacity in enhancing the growth stimulation effect of MK in NIH3T3 cells.

The silent epidemic of lymphogranuloma venereum inside the COVID-19 pandemic in Madrid, Spain, March 2020 to February 2021.

Despite social distancing measures implemented in Madrid to prevent the propagation of SARS-CoV-2, a significant increase (57.1%; 28.5 to 38.5 cases/month) in cases of lymphogranuloma venereum was detected during the COVID-19 pandemic. This unusual scenario might have accelerated a shift in Chlamydia trachomatis (CT) epidemiology towards a higher proportion of L genotypes compared with non-L genotypes in CT-positive samples. Our data underscore the importance of surveillance of sexually transmitted infections during the pandemic, in particular among vulnerable populations.

Orbital Cellulitis in Chagas Disease: An Unusual Presentation.

Chagas disease is an inflammatory, infectious disease caused by the parasite Trypanosoma cruzi found in the feces of the triatomine bug, which can cause a sudden, brief acute illness, or it may become a long-lasting chronic condition. Chagas disease is common in South America and Central America, however, the constantly expanding global community has brought Chagas disease to the forefront of non-endemic areas, particularly the United States and Europe. The authors present a case of a 47-year-old healthy farmer diagnosed with a right orbital cellulitis refractory to systemic antibiotics. Based on clinical symptoms, the patient's medical/demographical history and a proper differential diagnosis, an acute phase of Chagas disease was diagnosed. After antiparasitic treatment, the patient had a proper recovery and continued with a regular follow-up to monitor the possible development of a chronic phase.

Estimating the effectiveness of self-help groups on the adoption of secondary preventive measures by people living with HIV in Central America, 2012.

BACKGROUND: According to UNAIDS, the HIV epidemic has stabilized. This as a result of increased condom use and greater access to coverage for antiretroviral therapy (ART). In Central America, civil society organizations work with self-help groups (SHGs) organized in conjunction with public health services to implement interventions seeking to increase condom use and ART adherence for people living with HIV (PLH). METHOD: To analyze the effectiveness of SHGs in Central America aimed on increasing condom use and ART adherence in PLH, We conducted a cross-sectional study using a questionnaire and a random sample of 3024 intervention group and 1166 control group. Based on propensity scoring and one-to-one matching (with replacement), we formed a comparison group to help estimate the effectiveness of the above-mentioned intervention on two outcome variables (condom use and ART adherence). The internal consistency of the results was tested through weighted least squares (WLS) and instrumental variable (IV) regression. RESULTS: Although bivariate comparisons yielded differences between intervention and control group, we found no evidence that the intervention was effective; nor did we find evidence of a heterogeneous impact among countries after adjusting for propensity scoring and the IV model. The impact observed after performing raw comparisons of the indicators may be attributable to self-selection on the part of PLH rather than to the SHGs strategy. Our results demonstrate that it is imperative to use rigorous intervention evaluation methodology to validate the consistency of results. CONCLUSIONS: The intervention had no impact on the outcome indicators measured. We recommend prioritizing the allocation of economic resources for the implementation of interventions with previously proven effectiveness. We also recommend that future studies explore why the intervention failed to produce the expected impact on condom use and ART adherence.

[Health conditions and use of services amongindigenous peoples of Mexico]. / Condiciones de salud y uso de servicios en pueblos indígenas de México.

OBJECTIVE: To identify differences in socioeconomic indi-cators, health conditions and use of services between the indigenous (IP) and non-indigenous population (NIP) of the country. MATERIALS AND METHODS: Descriptive cross-sectional study carried out with information obtained by the 2018-19 National Health and Nutrition Survey. RESULTS: Most IP are in the lowest socioeconomic quintile and they use less health services. Indigenous women reported a higher number of children, as well as childbirth care with midwives. IP go for medical care to institutions for the population without social security as the first option but expressed less desire to return to the same place. CONCLUSIONS: IPs use less health services. An epidemiological panorama of double burden and inequity in access indicators that affect IP is configured. Reproductive health is the area where the greatest inequali-ties are observed.

OBJETIVO: Identificar diferencias en indicadores socioeco-nómicos, de condiciones de salud y uso de servicios entre la población indígena (PI) y no indígena (PNI) del país. MATERIAL Y MÉTODOS: Estudio trasversal descriptivo con información de la Encuesta Nacional de Salud y Nutrición 2018-19. RESULTADOS: La mayoría de la PI se encuentra en el quintil socioeconómico más bajo y usa menos los servi-cios de salud. Las mujeres indígenas reportaron un mayor número de hijos, así como atención del parto con parteras. La PI acude por atención médica a las instituciones para población sin seguridad social como primera opción, pero manifiesta menor deseo de regresar a atenderse al mismo lugar. CONCLUSIONES: La PI utiliza menos los servicios de salud. Se configura un panorama epidemiológico de doble carga e inequidad en indicadores de acceso que afecta a la PI. La salud reproductiva es el ámbito donde se observan las mayores desigualdades.

The Systemic Administration of the Chemokine CCL1 Evokes Thermal Analgesia in Mice Through the Activation of the Endocannabinoid System.

Apart from its involvement in immune functions, the chemokine CCL1 can participate in the modulation of nociceptive processing. Previous studies have demonstrated the hypernociceptive effect produced by CCL1 in the spinal cord, but its possible action on peripheral nociception has not yet been characterized. We describe here that the subcutaneous administration of CCL1 (1-10 µg/kg) produces dose-dependent and long-lasting increases in thermal withdrawal latencies measured by the unilateral hot plate test in mice. The antinociceptive nature of this effect is further supported by the reduction of spinal neurons expressing Fos protein in response to a noxious thermal stimulus observed after the administration of 10 µg/kg of CCL1. CCL1-induced antinociception was inhibited after systemic, but not spinal administration of the selective antagonist R243 (0.1-1 mg/kg), demonstrating the participation of peripheral CCR8 receptors. The absence of this analgesic effect in mice treated with a dose of cyclophosphamide that produces a drastic depletion of leukocytes suggests its dependency on white blood cells. Furthermore, whereas the antinociceptive effect of CCL1 was unaffected after the treatment with either the antagonist of opioid receptors naloxone or the cannabinoid type 1 receptor blocker AM251, it was dose-dependently inhibited after the administration of the CB2 receptor antagonist SR144528 (0.1-1 mg/kg). The detection by ELISA of an increased presence of the endocannabinoid 2-arachidonoylglycerol after the administration of an analgesic dose of CCL1 supports the notion that CCL1 can evoke thermal analgesia through the release of this endocannabinoid from circulating leukocytes.

[Certification of medical care facilities in Mexico: analysis of the incentives for its continuity.] / Certificación de establecimientos de atención médica en México: análisis de los incentivos para su continuidad.

OBJECTIVE: To analyze the possible effect of certification models and healthcare organizations' (HOs) participation incentives in the General Health Council certification process in the 1999-2017 period. MATERIALS AND METHODS: Official printed and online documents about HOs' certification were collected. Information from instances related to the process was requested through transparency mechanisms. Health organizations' participation in political-administrative periods between 1997-2017 was analyzed. RESULTS: The annual average participation in the certification process during the 1999-2000 period was 259.5 HOs; during the 2013-2016 period, the average was 72.5. Public units' participation in this process has been decreasing. In 2017, certified HO were <1%. CONCLUSIONS: No positive effects of adjustments to the certification model or the incentives applied were identified. Conversely, there is decreasing participation in the different political-administrative periods. The National HO Certification System and its possible effect on clinical quality must be thoroughly evaluated.

OBJECTIVE: Analizar el posible efecto de los modelos de certificación y de los incentivos implementados en la participación de establecimientos de atención médica (EAM) en la certificación del Consejo de Salubridad General entre 1999-2017. MATERIALS AND METHODS: Se colectaron documentos oficiales, impresos y en línea, sobre la certificación de EAM y se solicitó información a diversas instancias relacionadas mediante mecanismos de transparencia. Se analizó la participación de EAM en los períodos político-administrativos entre 1999-2017. RESULTS: El promedio anual de participación entre 1999-2000 fue de 259.5 EAM; entre 2013-2016, de 72.5. La participación de EAM públicos es decreciente. En 2017, los EAM certificados eran <1%. CONCLUSIONS: No se identificaron efectos positivos ni sostenidos de ajustes al modelo, ni de los incentivos implementados. Se observa disminución de la participación en los distintos periodos político-administrativos. Debe evaluarse profundamente el Sistema Nacional de Certificación de EAM y su posible efecto en la calidad clínica.