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Pollination interactions between plants bearing oil-flowers and oil-collecting bees are regarded as specialized, and within the major group of bees, oil-collecting bees are considered a special functional group of pollinators, yet they encompass a great diversity, not only at taxonomic level but also in morphological and behavioral aspects. Since the functional group of oil-collecting bees is functionally diverse, we examined whether these bees, despite their gross commonalities, may be exerting divergence within and among oil-flowered species or, alternatively, promoting convergence to some general oil-flower morphology that can be pollinated by a functional range of oil-bees. To answer this question, we recorded pollinator assemblages of 18 taxa of Nierembergia, as well as the foraging behavior, visitation frequency, and morphometric characterization of all oil-collecting bees species that pollinate the flowers of those taxa, by field observations and sampling. We found that the pollinator assemblages of the species and varieties of Nierembergia largely differed among taxa. 14 species of oil-collecting bees, belonging to the genera Chalepogenus, Centris, Tapinotaspis, Caenonomada, Tetrapedia, and Arhysoceble, were recorded as pollinators of Nierembergia flowers. These pollinator species varied in multivariate body size, rewards-gathering behavior, and way they carry out pollination on flowers. According to our results, Nierembergia flowers are pollinated by five functional groups of oil-collecting bees that presumably promote divergence within and among Nierembergia taxa. Floral resource-harvesting behavior of oil-collecting bees species that pollinate Nierembergia flowers would be a key feature in the definition of functional groups and in the diversification of flower features in Nierembergia.

La participación del estudiante de la asignatura “Intervención Fisioterapéutica”, en el área pediátrica, se centra en actividades de evaluación e intervención dirigidas a niños en la que se brinda orientación y educación encaminada a mejorar la calidad de vida de las familias del Programa Madre Canguro. El objetivo era afianzar el logro de competencias cognitivas, procedimentales, comunicativas y sociales, mediante una experiencia de enseñanza-aprendizaje que incorpore TIC, a través de gamificación.

El porfiriato fue un periodo en el que se vivió un gran crecimiento económico en México. Socialmente esta prosperidad se vio reflejada, entre otras cosas, en las grandes fiestas y eventos realizados por y para las familias de las clases altas privilegiadas. Por otra parte, hubo un auge en la producción de medios impresos, particularmente proliferaron las revistas dirigidas a las damas del hogar y de la aristocracia mexicana. Una de ellas fue Álbum de Damas, publicación que se mantuvo entre enero de 1907 y julio de 1908, en la que se incluía una sección donde se describían los principales eventos sociales de las clases altas. El objetivo de este artículo es analizar las redes aristocráticas reflejadas en dicha sección, Ecos sociales de la quincena, de la revista Álbum de Damas, en los 24 números publicados en 1907. Analizar la revista en general es revelador en cuanto a su intención, similar a la de otras revistas de la época dedicadas a las mujeres, de educar o instruir a la mujer mexicana de acuerdo con un modelo que cumpliera con los roles convenientes para la nación y para el desarrollo de los futuros ciudadanos que servirían a la patria. Pero centrar el análisis en la sección social de la revista nos presen-ta toda una nueva perspectiva, pues a través del análisis de redes se pudieron visibilizar conexiones muy reveladoras en cuanto a vida social, política, estatus, influencias de poder y economía. Entender estas conexiones nos da un enfoque alternativo para comprender las dinámicas económicas y políticas de esa clase encargada, tal vez de manera indirecta, de dirigir el rumbo del país.

Background Preemptive analgesia encompasses different perioperative interventions that have the final aim of decreasing postoperative pain and improving recovery. Recently, peripheral analgesic effects of oxytocinergic modulation have been suggested. In this regard, we tested the potential analgesic effects of subcutaneous oxytocin (OT) infiltration in patients submitted to laparoscopic cholecystectomy. Methods Thirty patients with similar general characteristics and medical physical conditions were evaluated. The patients were assigned by simple random selection to one of three groups: (a) OT group (n = 10), which received preincisional subcutaneous OT (4 µg/4 ml saline) in the surgical sites for trocar placements; (b) Lidocaine group (n = 10), which received subcutaneous lidocaine 1% (4 ml) in the surgical sites; and (c) Control group (n = 10), which did not receive any treatment. Then we measured the effect of those treatments on the hemodynamic variations produced as responses to the surgical incisions and trocar insertions (open port placements using the Hasson technique). Moreover, we assessed the intensity of postoperative pain with the visual analogue scale during recovery and 24 hr after surgery. Results Hemodynamic parameters were stable in both intervention groups (subcutaneous OT and lidocaine) during the surgical incisions and trocar placements, whereas a most likely sympathetic activation due to trocar insertions (open port placements) was not blunted in the placebo group. Furthermore, postoperative pain was diminished in both OT and lidocaine groups when compared to the control group. Conclusions Preincisional subcutaneous OT administration reduced the hemodynamic response produced by the latter. Furthermore, OT also diminished postoperative pain.

The execution of the learning model based on the challenges projects, whose final activity is student learning oriented to the practice of knowledge and development of professional skills in the marketing career, is carried out thanks to agreements signed with local and national companies. This work aims to carry out a systematic review of the trends on the criteria issued based on the results of the satisfaction survey applied to 78 owners and managers of related companies, after the students socialized the results with the presentation of their projects. It is proposed to reformulate and diversify the challenges projects considering the productive matrix, the environmental impacts, as well as the market trends, which will contribute to the Higher Technical Institute of Guayaquil achieving a greater reputation in the public education market, which will lead to greater demand in the quotas of their careers.

Diarrheal disease remains a leading cause of child death globally, especially in low and middle-income countries. Use of oral rehydration solution (ORS) for treatment of diarrhea in children, a very cost-effective intervention, remains below 50% in many countries. Here we use a multi-level longitudinal model to reveal important predictors of ORS use at the national level. The findings suggest that increasing government effectiveness along with increased implementation and affordability of community-based health programs can lead to substantial increases in ORS use. Key informant interviews with national health leaders in countries that significantly improved ORS coverage support these quantitative findings.

To investigate whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions.We analysed survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions, in which at least two surveys had been conducted since 1995. We calculated the composite coverage index, a function of essential maternal and child health intervention parameters. We adopted the wealth index, divided into quintiles from poorest to wealthiest, to investigate wealth-related inequalities in coverage. We quantified trends with time by calculating average annual change in index using a least-squares weighted regression. We calculated population attributable risk to measure the contribution of wealth to the coverage index.We noted large differences between the four regions, with a median composite coverage index ranging from 50.8% for West Africa to 75.3% for Southern Africa. Wealth-related inequalities were prevalent in all subregions, and were highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as we observed a higher coverage in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and we found no evidence of inequality reduction in Central Africa.Our data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability.Déterminer si les pays d'Afrique subsaharienne sont parvenus à réduire l'impact des inégalités de richesse sur la prise en charge des interventions de santé reproductives, maternelles et infantiles.Nous avons analysé des données d'enquêtes menées dans 36 pays regroupé en sous-régions (Afrique centrale, Afrique de l'Est, Afrique australe et Afrique de l'Ouest). Au moins deux enquêtes devaient dater d'après 1995. Nous avons calculé l'indice de prise en charge composite en fonction de plusieurs paramètres essentiels d'interventions de santé maternelle et infantile. Nous avons également adopté l'indice de richesse divisé en quintiles, du plus pauvre au plus nanti, afin d'étudier l'impact des inégalités de richesse dans cette prise en charge. Nous avons quantifié les tendances par rapport au temps, en calculant l'évolution annuelle moyenne de l'indice à l'aide de la régression des moindres carrés pondérés. Enfin, nous avons évalué le risque attribuable à la population pour mesurer la contribution de la richesse à l'indice de prise en charge.Nous avons remarqué des différences considérables entre les quatre régions, avec un indice médian de prise en charge composite allant de 50,8% en Afrique de l'Ouest à 75,3% en Afrique australe. Les inégalités liées à la richesse étaient très répandues dans toutes les sous-régions; les plus fortes ont été observées en Afrique de l'Ouest, les plus faibles en Afrique australe. Le revenu absolu n'est pas un indicateur valable car nous avons constaté une meilleure prise en charge dans la sous-région d'Afrique australe (environ 70%) que dans celles d'Afrique centrale et d'Afrique de l'Ouest (environ 40%) pour des revenus équivalents. La majorité des inégalités de prise en charge liées à la richesse ont diminué en Afrique australe, et nous n'avons trouvé aucune preuve de réduction des inégalités en Afrique centrale.Nos données montrent que la plupart des pays d'Afrique subsaharienne ont réussi à atténuer les inégalités de prise en charge liées à la richesse pour les services de santé essentiels, même en cas de conflit, de difficultés économiques ou d'instabilité politique.Investigar si los países del África subsahariana han logrado reducir las desigualdades relacionadas con la riqueza en la cobertura de las intervenciones sanitarias relativas a la salud reproductiva, materna, neonatal e infantil.Se analizaron los datos de las encuestas de 36 países, agrupados en las subregiones de África central, oriental, meridional y occidental, en los que se habían realizado por lo menos dos encuestas desde 1995. Se calculó el índice compuesto de cobertura, en función de los parámetros esenciales de las intervenciones sanitarias relativas a la salud maternoinfantil. Se adoptó el índice de riqueza, dividido en quintiles de más pobres a más ricos, para investigar las desigualdades de cobertura relacionadas con la riqueza. Se cuantificaron las tendencias con el tiempo al calcular el cambio anual medio del índice por medio de una regresión por mínimos cuadrados ponderados. También se calculó el riesgo atribuible a la población para medir la contribución de la riqueza al índice de cobertura.Se observaron grandes diferencias entre las cuatro regiones, con un índice compuesto medio de cobertura que oscilaba entre el 50,8 % para el África occidental y el 75,3 % para el África meridional. Las desigualdades relacionadas con la riqueza prevalecían en todas las subregiones y eran mayores en el África occidental y menores en el África meridional. Los ingresos absolutos no eran un factor de predicción de la cobertura, ya que se observó una mayor cobertura en las subregiones del sur (alrededor del 70 %) en comparación con las subregiones central y occidental (alrededor del 40 %) para los mismos ingresos. Las desigualdades de cobertura relacionadas con la riqueza se redujeron en mayor medida en el África meridional, y no encontramos pruebas de reducción de la desigualdad en el África central.Estos datos muestran que la mayoría de los países del África subsahariana han logrado reducir las desigualdades relacionadas con la riqueza en la cobertura de los servicios sanitarios esenciales, incluso en presencia de conflictos, dificultades económicas o inestabilidad política.الغرض التحقق مما إذا كانت الدول الأفريقية في جنوب الصحراء الكبرى قد نجحت في الحد من حالات عدم المساواة المتعلقة بالثروة في تغطية التدخلات الصحية المتعلقة بالصحة الإنجابية، وصحة الأم، وصحة المواليد، وصحة الأطفال. الطريقة قمنا بتحليل بيانات المسح من 36 دولة، ثم تجميعها في مناطق وسط وشرق وجنوب وغرب إفريقيا الفرعية، والتي تم فيها إجراء مسحين على الأقل منذ عام 1995. وقمنا بحساب مؤشر التغطية المركبة، وهي وظيفة لمعاملات التدخل الصحي الأساسية للأم والطفل. قمنا بانتهاج مؤشر الثروة، وقسمناه إلى الفئات الخمسية من الأشد فقراً إلى الأكثر غنى، للتحقيق في حالات عدم المساواة المتعلقة بالثروة في التغطية. وقمنا بقياس الاتجاهات مع مرور الوقت عن طريق حساب متوسط ​​التغيير السنوي في المؤشر باستخدام انحدار المربعات الصغرى المرجح. قمنا بحساب المخاطر التي تعزى إلى السكان لقياس مساهمة الثروة في مؤشر التغطية. النتائج لاحظنا وجود اختلافات كبيرة بين المناطق الأربع، مع متوسط ​​للمؤشر المركب للتغطية من 50.8% في غرب إفريقيا إلى 75.3% في جنوب أفريقيا. كانت حالات عدم المساواة المتعلقة بالثروة سائدة في كل المناطق الفرعية، وكانت في أعلى درجاتها في غرب أفريقيا، وأدنى درجاتها في جنوب أفريقيا. لم يكن الدخل المطلق عاملاً للتنبؤ بالتغطية، حيث لاحظنا تغطية أعلى في المناطق الجنوبية (حوالي 70%) مقارنة بالمناطق الفرعية الوسطى والغربية (حوالي 40%) لنفس الدخل. تقلصت حالات عدم المساواة في التغطية المتعلقة بالثروة، بأكبر قدر ممكن في جنوب أفريقيا، بينما لم نجد دليلاً على الحد من عدم المساواة في وسط أفريقيا.تُظهر بياناتنا أن معظم الدول الأفريقية في جنوب الصحراء الكبرى قد نجحت في الحد من حالات عدم المساواة المتعلقة بالثروة في تغطية الخدمات الصحية الأساسية، حتى في وجود الصراع، أو الصعوبات الاقتصادية، أو عدم الاستقرار السياسي旨在调查撒哈拉以南的非洲国家是否成功减少了在生育、孕产妇、新生儿和儿童健康干预措施覆盖方面呈现出的与财富有关的不平等现象。.我们分析了来自中非、东非、南非和西非地区的 36 个国家的调查数据，这些国家自 1995 年以来已至少进行了两次调查。我们计算了综合覆盖指数，这是一种妇幼健康干预基本参数函数。我们采用财富指数，从最贫困到最富有共划分了五个等级，以调查在覆盖范围方面与财富相关的不平等现象。我们使用最小二乘加权回归法计算指数的年平均变化，从而量化其随时间的变化趋势。我们计算了人群归因风险度来衡量财富对覆盖指数的贡献。.我们发现这四个地区之间存在巨大差异，综合覆盖指数中位数从西非的 50.8%，到南非的 75.3%。与财富有关的不平等现象普遍存在于非洲各个次区域，其中西非的不平等程度最高，南非的不平等程度最低。我们观察到，在相同的收入水平下，南部地区（约 70%）的覆盖率高于中部和西部地区（约 40%），因此绝对收入并非覆盖率的预测指标。与财富相关的不平等现象在非洲南部减少最多，而在中非，我们没有发现不平等现象减少的迹象。.我们的数据显示，即使存在冲突、经济困难或政治动荡问题，大多数撒哈拉以南的非洲国家在基本卫生服务覆盖方面成功地减少了与财富相关的不平等现象。.Изучить, удалось ли странам Африки, расположенным южнее Сахары, успешно сократить неравенство в охвате мероприятиями по охране репродуктивного здоровья, материнства, здоровья новорожденных и детского здравоохранения, связанное с уровнем доходов.Авторы проанализировали данные опросов в 36 странах, сгруппированных в субрегионы Восточной, Западной, Центральной и Южной Африки, в которых в период с 1995 года было проведено по меньшей мере два опроса. Авторы рассчитали составной индекс охвата как функцию существенных параметров мероприятий по охране здоровья матери и ребенка. За основу был взят показатель благосостояния, разбитый на квинтили от самых бедных до самых богатых, позволяющий изучить неравенство в охвате мероприятиями, связанное с различиями в уровне доходов. Авторы выполнили количественную оценку тенденций по времени посредством расчета среднегодового изменения показателя с использованием средневзвешенной регрессии по методу наименьших квадратов. Авторы рассчитали популяционный риск, чтобы измерить зависимость показателя охвата мероприятиями от уровня дохода.Было отмечено значительное различие между четырьмя регионами: средний составной индекс охвата составил от 50,8% в Западной Африке до 75,3% в Южной Африке. Неравенство, связанное с уровнем доходов, присутствовало во всех субрегионах и было сильнее всего выражено в странах Западной Африки и слабее всего выражено в странах Южной Африки. Абсолютный доход не позволял прогнозировать уровень охвата мероприятиями по охране здоровья, поскольку авторы наблюдали более высокий уровень охвата (около 70%) в Южной Африке по сравнению с уровнем охвата в Центральном и Западном субрегионах (около 40%) при том же уровне дохода. Неравенство, связанное с различиями в уровне дохода, значительно уменьшилось в Южной Африке, тогда как в Центральной Африке снижения неравенства не отмечается.Данные показывают, что большинству стран Африки, расположенных южнее Сахары, удалось сократить неравенство в охвате основными видами медицинских услуг, связанное с уровнем доходов, несмотря на наличие конфликтов, тяжелой экономической ситуации или политической нестабильности.

Subnational inequalities have received limited attention in the monitoring of progress towards national and global health targets during the past two decades. Yet, such data are often a critical basis for health planning and monitoring in countries, in support of efforts to reach all with essential interventions. Household surveys provide a rich basis for interventions coverage indicators on reproductive, maternal, newborn and child health (RMNCH) at the country first administrative level (regions or provinces). In this paper, we show the large subnational inequalities that exist in RMNCH coverage within 39 countries in sub-Saharan Africa, using a composite coverage index which has been used extensively by Countdown to 2030 for Women’s, Children’s and Adolescent’s Health. The analyses show the wide range of subnational inequality patterns such as low overall national coverage with very large top inequality involving the capital city, intermediate national coverage with bottom inequality in disadvantaged regions, and high coverage in all regions with little inequality. Even though nearly half of the 34 countries with surveys around 2004 and again around 2015 appear to have been successful in reducing subnational inequalities in RMNCH coverage, the general picture shows persistence of large inequalities between subnational units within many countries. Poor governance and conflict settings were identified as potential contributing factors. Major efforts to reduce within-country inequalities are required to reach all women and children with essential interventions.

CONTEXT: Although adolescent mental health interventions are widely implemented, little consensus exists about elements comprising successful models. OBJECTIVE: We aimed to identify effective program components of interventions to promote mental health and prevent mental disorders and risk behaviors during adolescence and to match these components across these key health outcomes to inform future multicomponent intervention development. DATA SOURCES: A total of 14 600 records were identified, and 158 studies were included. STUDY SELECTION: Studies included universally delivered psychosocial interventions administered to adolescents ages 10 to 19. We included studies published between 2000 and 2018, using PubMed, Medline, PsycINFO, Scopus, Embase, and Applied Social Sciences Index Abstracts databases. We included randomized controlled, cluster randomized controlled, factorial, and crossover trials. Outcomes included positive mental health, depressive and anxious symptomatology, violence perpetration and bullying, and alcohol and other substance use. DATA EXTRACTION: Data were extracted by 3 researchers who identified core components and relevant outcomes. Interventions were separated by modality; data were analyzed by using a robust variance estimation meta-analysis model, and we estimated a series of single-predictor meta-regression models using random effects. RESULTS: Universally delivered interventions can improve adolescent mental health and reduce risk behavior. Of 7 components with consistent signals of effectiveness, 3 had significant effects over multiple outcomes (interpersonal skills, emotional regulation, and alcohol and drug education). LIMITATIONS: Most included studies were from high-income settings, limiting the applicability of these findings to low- and middle-income countries. Our sample included only trials. CONCLUSIONS: Three program components emerged as consistently effective across different outcomes, providing a basis for developing future multioutcome intervention programs.

En el primer capítulo, se describe al hotel y su historia, el hospedaje posee una categoría de tres estrellas, está situado en la ciudad de Trujillo, inició operaciones en el año 2017, y actualmente se desenvuelve en un ambiente altamente competitivo debido a la variada oferta de hospedajes. En el segundo capítulo, se realizó el análisis situacional de la empresa, la cual presenta un bajo volumen de ventas, con un promedio de ocupabilidad del treinta por ciento de su máxima capacidad instalada de habitaciones. Es por ello, que con el fin de incrementar las ventas, se clasifica el ingreso de ventas por dos grupos de clientes: aquellos que acuden al establecimiento por primera vez (venta por captación de nuevos clientes), y aquellos que ya experimentaron el servicio y deciden regresar (venta por recompra). En el tercer capítulo, se diagnosticó el problema utilizando diversas herramientas de análisis, a fin de determinar sus causas y efectos; estas se resumen y analizan mediante la herramienta del diagrama de árbol de problemas, identificando que la raíz del problema se debe a la falta de un plan de marketing de servicios. Una vez diagnosticado el problema, el cuarto capítulo precisa analizar las fuentes del problema y escoger alternativas de solución enfocadas en el problema o fuente principal. En esta sección ha sido fundamental aplicar el método de Goal Tree que permite una visión integral del negocio al reflejar la relación de causa-efecto entre las alternativas que ayuda a cumplir objetivos. El quinto capítulo trata la propuesta de mejora, desarrollando todas las aristas del plan de marketing enfocado en los clientes (la recompra) y clientes potenciales (captar nuevos huéspedes). Determinando las posibles soluciones, el capítulo seis será dedicado a la validación y evaluación de las propuestas de mejora. Trabajo de investigación

Background: Each year an estimated 2.6 million newborns die, mainly from complications of prematurity, neonatal infections, and intrapartum events. Reducing these deaths requires high coverage of good quality care at birth, and inpatient care for small and sick newborns. In low- and middle-income countries, standardised measurement of the readiness of facilities to provide emergency obstetric care has improved tracking of readiness to provide care at birth in recent years. However, the focus has been mainly on obstetric care; service readiness for providing inpatient care of small and sick newborns is still not consistently measured or tracked. Methods: We reviewed existing international guidelines and resources to create a matrix of the structural characteristics (infrastructure, equipment, drugs, providers and guidelines) for service readiness to deliver a package of inpatient care interventions for small and sick newborns. To identify gaps in existing measurement systems, we reviewed three multi-country health facility survey tools (the Service Availability and Readiness Assessment, the Service Provision Assessment and the Emergency Obstetric and Newborn Care Assessment) against our service readiness matrix. Findings: For service readiness to provide inpatient care for small and sick newborns, our matrix detailed over 600 structural characteristics. Our review of the SPA, the SARA and the EmONC assessment tools identified several measurement omissions to capture information on key intervention areas, such as thermoregulation, feeding and respiratory support, treatment of specific complications (seizures, jaundice), and screening and follow up services, as well as specialised staff and service infrastructure. Conclusions: Our review delineates the required inputs to ensure readiness to provide inpatient care for small and sick newborns. Based on these findings, we detail where questions need to be added to existing tools and describe how measurement systems can be adapted to reflect small and sick newborns interventions. Such work can inform investments in health systems to end preventable newborn death and disability as part of the Every Newborn Action Plan.

Background Thermal care of newborns is one of the recommended strategies to reduce hypothermia, which contributes to neonatal morbidity and mortality. However, data on these two topics have not been collected at the national level in many surveys. In this study, we examine two elements of thermal care: drying and delayed bathing of newborns after birth with the objectives of examining how two countries collected such data and then looking at various associations of these outcomes with key characteristics. Further, we examine the data for potential data quality issues as this is one of the first times that such data are available at the national level. Methods We use data from two nationally-representative household surveys: the Malawi Multiple Indicator Cluster Survey 2014 and the Bangladesh Demographic and Health Survey 2014. We conduct descriptive analysis of the prevalence of these two newborn practices by various socio-demographic, economic and health indicators. Results Our results indicate high levels of immediate drying/drying within 1 hour in Malawi (87%). In Bangladesh, 84% were dried within the first 10 minutes of birth. Bathing practices varied in the two settings; in Malawi, only 26% were bathed after 24 hours but in Bangladesh, 87% were bathed after the same period. While in Bangladesh there were few newborns who were never bathed (less than 5%), in Malawi, over 10% were never bathed. Newborns delivered by a skilled provider tended to have better thermal care than those delivered by unskilled providers. Conclusion These findings reveal gaps in coverage of thermal care and indicate the need to further develop the role of unskilled providers who can give unspecialized care as a means to improve thermal care for newborns. Further work to harmonize data collection methods on these topics is needed to ensure comparable data across countries.

Background Health facility service environment is an important factor for newborns survival and well–being in general and in particular in high mortality settings such as Malawi where despite high coverage of essential interventions, neonatal mortality remains high. The aim of this study is to assess whether the quality of the health service environment at birth is associated with quality of care received by the newborn. Methods We used data from the Malawi Millennium Development Goals Endline household survey conducted as part of MICS survey program and Service Provision Assessment Survey carried out in 2014. The analysis is based on 6218 facility births that occurred during the past 2 years. Descriptive statistics, bivariate and multivariate random effect models are used to assess the association of health facility service readiness score for normal deliveries and newborn care with newborns receiving appropriate newborn care, defined for this analysis as receiving 5 out of 6 recommended interventions during the first 2 days after birth. Results Newborns in districts with top facility service readiness score have 1.5 higher odds of receiving appropriate newborn care (adjusted odds ratio (aOR) = 1.52, 95% confidence interval CI = 1.19–1.95, P = 0.001), as compared to newborns in districts with a lower facility score after adjusting for potential confounders. Newborns in the Northern region were two times more likely to receive 5 newborn care interventions as compared to newborns in the Southern region (aOR = 2.06, 95% CI = 1.50–2.83, P

Background Recent studies have shown higher neonatal mortality among births delivered by a skilled attendant at birth (SAB) compared to those who were not in sub-Saharan African countries. Deaths during the neonatal period are concentrated in the first 7 days of life, with about one third of these deaths occurring during the first day of life. We reassessed the relationship between SAB and neonatal mortality by distinguishing deaths on the first day of life from those on days 2-27. Methods We used data on births in the past five years from recent demographic and health survey (DHS) between 2010 and 2014 in 20 countries in sub-Saharan Africa. The main categorical outcome was 1) newborns who died within the first day of birth (day 0-1), 2) newborns who died between days 2-27, and 3) newborns who survived the neonatal period. We ran generalized linear mixed model with multinomial distribution and random effect for country on pooled data. Additionally, we ran a separate model restricted to births with SAB and assessed the association of receipt of seven antenatal care (ANC) and two immediate postnatal care interventions on risk of death on days 0-1 and days 2-27. These variables were assessed as proxy of quality of antenatal and postnatal care. Results We found no statistically significant difference in risk of death on first day of life between newborns with SAB compared to those without. However, after the first day of life, newborns delivered with SAB were 16% less likely to die within 2-27 days than those without SAB (OR = 0.84, 95% CI = 0.71-0.99). Among births with skilled attendant, those who were weighed at birth and those who were initiated early on breastfeeding were significantly less likely to die on days 0-1 (respectively OR = 0.42 95% CI = 0.29-0.62 and OR = 0.24, 95% CI 0.18-0.31) or on days 2-27 (OR = 0.60, 95% CI = 0.45-0.81 and OR = 0.59, 95% CI = 47-0.74, respectively). Newborns whose mothers received an additional ANC intervention had no improved survival chances during days 0-1 of life. However, there was significant association on days 2-27 where newborns whose mothers received an additional ANC interventions had higher survival chances (OR = 0.95, 95% CI = 0.93-0.98). Conclusion Findings demonstrate the vulnerability of newborns immediately after birth, compounded with insufficient quality of care. Improving the quality of care around the time of birth will significantly improve survival and therefore accelerate reduction in neonatal mortality in sub-Saharan African countries. Improved approaches for measuring skilled attendant at birth are also needed.

Background Over the last decade, coverage of maternal and newborn health indicators used for global monitoring and reporting have increased substantially but reductions in maternal and neonatal mortality have remained slow. This has led to an increased recognition and concern that these standard globally agreed upon measures of antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) only capture the level of contacts with the health system and provide little indication of actual content of services received by mothers and their newborns. Over this period, large household surveys have captured measures of maternal and newborn care mainly through questions assessing contacts during the antenatal, delivery and postnatal periods along with some measures of content of care. This study aims to describe the gap between contact and content -as a proxy for quality- of maternal and newborn health services by assessing level of co-coverage of ANC and PNC interventions. Methods We used Demographic and Health Surveys (DHS) data from 20 countries between 2010 and 2015. We analysed the proportion of women with at least 1 and 4+ antenatal care visit, who received 8 interventions. We also assessed the percentage of newborns delivered with a skilled birth attendant who received 7 interventions. We ran random effect logistic regression to assess factors associated with receiving all interventions during the antenatal and postnatal period. Results While on average 51% of women in the analysis received four ANC visits with at least one visit from a skilled health provider, only 5% of them received all 8 ANC interventions. Similarly, during the postnatal period though two-thirds (65%) of births were attended by a skilled birth attendant, only 3% of newborns received all 7 PNC interventions. The odds of receiving all ANC and PNC interventions were higher for women with higher education and higher wealth status. Conclusion The gap between coverage and content as a proxy of quality of antenatal and postnatal care is excessively large in all countries. In order to accelerate maternal and newborn survival and achieve Sustainable Development Goals, increased efforts are needed to improve both the coverage and quality of maternal and newborn health interventions.

Background The postnatal period represents a vulnerable phase for mothers and newborns where both face increased risk of morbidity and death. WHO recommends postnatal care (PNC) for mothers and newborns to include a first contact within 24 hours following the birth of the child. However, measuring coverage of PNC in household surveys has been variable over time. The two largest household survey programs in low and middle-income countries, the UNICEF-supported Multiple Indicator Cluster Surveys (MICS) and USAID-funded Demographic and Health Surveys (DHS), now include modules that capture these measures. However, the measurement approach is slightly different between the two programs. We attempt to assess the possible measurement differences that might affect comparability of coverage measures. Methods We first review the standard questionnaires of the two survey programs to compare approaches to collecting data on postnatal contacts for mothers and newborns. We then illustrate how the approaches used can affect PNC coverage estimates by analysing data from four countries; Bangladesh, Ghana, Kygyz Republic, and Nepal, with both MICS and DHS between 2010-2015. Results We found that tools implemented todate by MICS and DHS (up to MICS round 5 and up to DHS phase 6) have collected PNC information in different ways. While MICS dedicated a full module to PNC and distinguishes immediate vs later PNC, DHS implemented a more blended module of pregnancy and postnatal and did not systematically distinguish those phases. The two survey programs differred in the way questions on postnatal care for mothers and newbors were framed. Subsequently, MICS and DHS surveys followed different methodological approach to compute the global indicator of postnatal contacts for mothers and newborns within two days following delivery. Regardless of the place of delivery, MICS estimates for postnatal contacts for mothers and newbors appeared consistently higher than those reported in DHS. The difference was however, far more pronounced in case of newborns. Conclusions Difference in questionnaires and the methodology adopted to measure PNC have created comparability issues in the coverage levels. Harmonization of survey instruments on postnatal contacts will allow comparable and better assessment of coverage levels and trends.

Background Skin-to-skin contact (SSC) between mother and newborn offers numerous protective effects, however it is an intervention that has been under-utilized. Our objectives are to understand which newborns in Bangladesh and Nigeria receive SSC and whether SSC is associated with the early initiation of breastfeeding. Methods Demographic and Health Survey (DHS) data were used to study the characteristics of newborns receiving SSC for non-facility births in Nigeria (DHS 2013) and for both facility and non-facility births in Bangladesh (DHS 2014). Multivariable logistic regression was used to study the association between SSC and early initiation of breastfeeding after controlling for key socio-demographic, maternal and newborn-related factors. Results Only 10% of newborns in Nigeria and 26% of newborns in Bangladesh received SSC. In the regression models, SSC was significantly associated with the early initiation of breastfeeding in both countries (OR = 1.42, 95% CI 1.15-1.76 for Nigeria; OR = 1.27, 95% CI 1.04-1.55, for Bangladesh). Findings from the regression analysis for Bangladesh revealed that newborns born by Cesarean section had a 67% lower odds of early initiation of breastfeeding than those born by normal delivery (OR = 0.33, 95% CI 0.26-0.43). Also in Bangladesh newborns born in a health facility had a 30% lower odds of early initiation of breastfeeding than those born in non-facility environments (OR = 0.70, 95% CI 0.53-0.92). Early initiation of breastfeeding was significantly associated with parity, urban residence and wealth in Nigeria. Geographic area was significant in the regression analyses for both Bangladesh and Nigeria. Conclusions Coverage of SSC is very low in the two countries, despite its benefits for newborns without complications. SSC has the potential to save newborn lives. There is a need to prioritize training of health providers on the implementation of essential newborn care including SSC. Community engagement is also needed to ensure that all women and their families regardless of residence, socio-economic status, place or type of delivery, understand the benefits of SSC and early initiation of breastfeeding.

Background Aside from breastfeeding, there are little data on use of essential newborn care practices, such as thermal protection and hygienic cord care, in high mortality countries. These practices have not typically been measured in national household surveys, often the main source for coverage data in these settings. The Every Newborn Action Plan proposed early breastfeeding as a tracer for essential newborn care due to data availability and evidence for the benefits of breastfeeding. In the past decade, a few national surveys have added questions on other practices, presenting an opportunity to assess the performance of early breastfeeding initiation as a tracer indicator. Methods We identified twelve national surveys between 2005-2014 that included at least one indicator for immediate newborn care in addition to breastfeeding. Because question wording and reference populations varied, we standardized data to the extent possible to estimate coverage of newborn care practices, accounting for strata and multistage survey design. We assessed early breastfeeding as a tracer by: 1) examining associations with other indicators using Pearson correlations; and 2) stratifying by early breastfeeding to determine differences in coverage of other practices for initiators vs non-initiators in each survey, then pooling across surveys for a meta-analysis, using the inverse standard error as the weight for each observation. Findings Associations between pairs of coverage indicators are generally weak, including those with breastfeeding. The exception is drying and wrapping, which have the strongest association of any two interventions in all five surveys where measured; estimated correlations for this range from 0.47 in Bangladesh's 2007 DHS to 0.83 in Nepal's 2006 DHS. The contrast in coverage for other practices by early breastfeeding is generally small; the greatest absolute difference was 6.7%, between coverage of immediate drying for newborns breastfed early compared to those who were not. Conclusions Early initiation of breastfeeding is not a high performing tracer indicator for essential newborn care practices measured in previous national surveys. To have informative data on whether newborns are getting life-saving services, standardized questions about specific practices, in addition to breastfeeding initiation, need to be added to surveys.

Background Research shows inadequate Integrated Management of Childhood Illness (IMCI)–pneumonia care in various low–income settings but evidence is largely from small–scale studies with limited evidence of patient–, provider– and facility–levels determinants of IMCI non–severe pneumonia classification and its management. Methods The Malawi Service Provision Assessment 2013–2014 included 3149 outpatients aged 2–59 months with completed observations, interviews and re–examinations. Mixed–effects logistic regression models quantified the influence of patient–, provider and facility–level determinants on having IMCI non–severe pneumonia and its management in observed consultations. Findings Among 3149 eligible outpatients, 590 (18.7%) had IMCI non–severe pneumonia classification in re–examination. 228 (38.7%) classified cases received first–line antibiotics and 159 (26.9%) received no antibiotics. 18.6% with cough or difficult breathing had 60–second respiratory rates counted during consultations, and conducting this assessment was significantly associated with IMCI training ever received (odds ratio (OR) = 2.37, 95% confidence interval (CI): 1.29–4.31) and negative rapid diagnostic test results (OR = 3.21, 95% CI: 1.45–7.13). Older children had lower odds of assessments than infants (OR = 48–59 months: 0.35, 95% CI: 0.16–0.75). Children presenting with any of the following complaints also had reduced odds of assessment: fever, diarrhea, skin problem or any danger sign. First–line antibiotic treatment for classified cases was significantly associated with high temperatures (OR = 3.26, 95% CI: 1.24–8.55) while older children had reduced odds of first–line treatment compared to infants (OR = 48–59 months: 0.29, 95% CI: 0.10–0.83). RDT–confirmed malaria was a significant predictor of no antibiotic receipt for IMCI non–severe pneumonia (OR = 10.65, 95% CI: 2.39–47.36). Conclusions IMCI non–severe pneumonia care was sub–optimal in Malawi health facilities in 2013–2014 with inadequate assessments and prescribing practices that must be addressed to reduce this leading cause of mortality. Child’s symptoms and age, malaria diagnosis and provider training were primary influences on assessment and treatment practices. Current evidence could be used to better target IMCI training and support to improve pneumonia care for sick children in Malawi facilities.

IntroductionDespite progress towards the Millennium Development Goals (MDG), maternal mortality remains high in countries where there are shortages of skilled personnel able to manage and provide quality care during pregnancy and childbirth. The ‘percentage of births attended by skilled health personnel’ (SAB, skilled attendants at birth) was a key indicator for tracking progress since the MDGs and is part of the Sustainable Development Goal agenda. However, due to contextual differences between and within countries on the definition of SAB, a lack of clarity exists around the training, competencies, and skills they are qualified to perform. In this paper, we outline a scoping review protocol that poses to identify and map the health personnel considered SAB in low and middle-income countries (LMIC).Methods and analysisA search will be conducted for the years 2000–2015 in PubMed/MEDLINE, EMBASE, CINAHL Complete, Cochrane Database of Systematic Reviews, POPLINE and the WHO Global Health Library. A manual search of reference lists from identified studies or systematic reviews and a hand search of the literature from international partner organisations will be done. Original studies conducted in LMIC that assessed health personnel (paid or voluntary) providing interventions during the intrapartum period will be considered for inclusion.Ethics and disseminationA scoping review is a secondary analysis of published literature and does not require ethics approval. This scoping review proposes to synthesise data on the training, competency and skills of identified SAB and expands on other efforts to describe this global health workforce. The results will inform recommendations around improved coverage measurement and reporting of SAB moving forward, allowing for more accurate, consistent and timely data able to guide decisions and action around planning and implementation of maternal and newborn health programme globally. Data will be disseminated through a peer-reviewed manuscript, conferences and to key stakeholders within international organisations.

Summary Building upon the successes of Countdown to 2015, Countdown to 2030 aims to support the monitoring and measurement of women's, children's, and adolescents' health in the 81 countries that account for 95% of maternal and 90% of all child deaths worldwide. To achieve the Sustainable Development Goals by 2030, the rate of decline in prevalence of maternal and child mortality, stillbirths, and stunting among children younger than 5 years of age needs to accelerate considerably compared with progress since 2000. Such accelerations are only possible with a rapid scale-up of effective interventions to all population groups within countries (particularly in countries with the highest mortality and in those affected by conflict), supported by improvements in underlying socioeconomic conditions, including women's empowerment. Three main conclusions emerge from our analysis of intervention coverage, equity, and drivers of reproductive, maternal, newborn, and child health (RMNCH) in the 81 Countdown countries. First, even though strong progress was made in the coverage of many essential RMNCH interventions during the past decade, many countries are still a long way from universal coverage for most essential interventions. Furthermore, a growing body of evidence suggests that available services in many countries are of poor quality, limiting the potential effect on RMNCH outcomes. Second, within-country inequalities in intervention coverage are reducing in most countries (and are now almost non-existent in a few countries), but the pace is too slow. Third, health-sector (eg, weak country health systems) and non-health-sector drivers (eg, conflict settings) are major impediments to delivering high-quality services to all populations. Although more data for RMNCH interventions are available now, major data gaps still preclude the use of evidence to drive decision making and accountability. Countdown to 2030 is investing in improvements in measurement in several areas, such as quality of care and effective coverage, nutrition programmes, adolescent health, early childhood development, and evidence for conflict settings, and is prioritising its regional networks to enhance local analytic capacity and evidence for RMNCH.

IntroductionThe private sector accounts for an important share of health services available in South Asia. It is not known to what extent socioeconomic and urban–rural inequalities in maternal, newborn and child health (MNCH) interventions are being affected by the presence of private providers.MethodsNationally representative surveys carried out from 2009 to 2015 were analysed for seven of the eight countries in South Asia, as data for Sri Lanka were not available. The outcomes studied included antenatal care (four or more visits), institutional delivery, early initiation of breast feeding, postnatal care for babies, and careseeking for diarrhoea and pneumonia. Results were stratified according to quintiles of household wealth and urban–rural residence.ResultsAt regional level, the public sector played a larger role than the private sector in providing antenatal (24.8% vs 15.6% coverage), delivery (51.9% vs 26.8%) and postnatal care (15.7% vs 8.2%), as well as in the early initiation of breast feeding (26.1% vs 11.1%). The reverse was observed in careseeking for diarrhoea (15.0% and 46.2%) and pneumonia (18.2% and 50.5%). In 28 out of 37 possible analyses of coverage by country, socioeconomic inequalities were significantly wider in the private than in the public sector, and in only four cases the reverse pattern was observed. In 20 of the 37 analyses, the public sector was also more likely to be used by the wealthiest women and children.ConclusionThe private sector plays a substantial role in delivering MNCH interventions in South Asia but is more inequitable than the public sector.

We developed a PCR-based assay to differentiate medically important species of Aspergillus from one another and from other opportunistic molds and yeasts by employing universal, fungus-specific primers and DNA probes in an enzyme immunoassay format (PCR-EIA). Oligonucleotide probes, directed to the internal transcribed spacer 2 region of ribosomal DNA from Aspergillus flavus , Aspergillus fumigatus , Aspergillus nidulans , Aspergillus niger , Aspergillus terreus , Aspergillus ustus , and Aspergillus versicolor , differentiated 41 isolates (3 to 9 each of the respective species; P < 0.001) in a PCR-EIA detection matrix and gave no false-positive reactions with 33 species of Acremonium , Exophiala , Candida , Fusarium , Mucor , Paecilomyces , Penicillium , Rhizopus , Scedosporium , Sporothrix , or other aspergilli tested. A single DNA probe to detect all seven of the most medically important Aspergillus species ( A. flavus , A. fumigatus , A. nidulans , A. niger , A. terreus , A. ustus , and A. versicolor ) was also designed. Identification of Aspergillus species was accomplished within a single day by the PCR-EIA, and as little as 0.5 pg of fungal DNA could be detected by this system. In addition, fungal DNA extracted from tissues of experimentally infected rabbits was successfully amplified and identified using the PCR-EIA system. This method is simple, rapid, and sensitive for the identification of medically important Aspergillus species and for their differentiation from other opportunistic fungi.

El presente ensayo destaca el papel del rectorado en los procesos de evaluación y acreditación internacional de las instituciones de educación superior, pues su visión e involucramiento pueden contribuir a mantener el enfoque del proceso como medio para fomentar la calidad en la institución. Sin entrar en el debate que ha implicado la inclusión del concepto de calidad educativa, este trabajo trata de responder a la siguiente interrogante: ¿qué estilo de liderazgo deberá ejercer el rector o rectora de una institución de educación superior que se embarca en proceso de evaluación o acreditación internacional? El trabajo concluye que el liderazgo del rectorado es una piedra angular en el establecimiento de una cultura de calidad en las instituciones de educación superior, así como en los procesos de evaluación y acreditación internacional, y señala que los estilos de liderazgo más importantes en estos procesos son: el liderazgo transformacional, el liderazgo trascendente y el liderazgo transaccional.

ResumenIntroducciónLos alumnos pueden ser tutores en medicina en clínica u otras áreas.ObjetivoEvaluar las habilidades docentes de alumnos tutores en un curso de investigación por lectura crítica durante el internado de pregrado.Material y métodosSe estudiaron dos grupos, G1 (n=5) con un profesor y discusión grupal y G2 con cuatro alumnos tutores y discusión subgrupal (n=10). El curso duró 40 horas, se desarrolló con resolución de guías de lectura en casa y la discusión referida. Se aplicaron cinco instrumentos: 1) lectura crítica con 108 reactivos, 2) actividades subgrupales del profesor con 17 reactivos, 3) actividades de los estudiantes en la discusión subgrupal con 18 reactivos, 4) evaluación de aspectos cualitativos por los estudiantes al tutor con 8 reactivos y 5) una autoevaluación del alumno tutor con 10 reactivos. Los instrumentos 1, 2 y 4 se evaluaron antes y después del curso. El instrumento 1 se calificó sumando las respuestas correctas y restando las incorrectas utilizando las medianas. Se compararon ambos grupos (U de Mann Whitney y Wilcoxon) el avance ponderal y el azar. Se utilizó una escala de Likert con valor de 1 (mínimo) al 4 (máximo) en los instrumentos 2 al 5; los valores se sumaron y se utilizaron medianas. Se determinó la consistencia en los instrumentos 1 al 4.ResultadosEn la lectura crítica no se observaron cambios significativos entre ambos grupos antes y después de las intervenciones, pero se observó avance ponderal y disminución del azar en G2. Los instrumentos 2, 3, 4 (Alfa de Cronbach > 0.75) reportaron medianas adecuadas en casi todos los aspectos. En instrumento 2, resultados cercanos al máximo al final en G2. Los tutores incrementan el afecto por sus alumnos.DiscusiónAlumnos tutores pueden desarrollar habilidades docentes complejas apoyando el aprendizaje en estudiantes. Estas estrategias están subutilizadas en nuestro medio.AbstractIntroductionStudents may be tutors in clinical medicine and other areas.ObjectiveTo evaluate the teaching abilities of students as tutors in a critical appraisal research course, during their internship.Material and MethodsTwo groups were studied: G1 (n=5) was taught by a Professor and included group discussions, and G2 had four student tutors and engaged in sub-group discussions (n=10). The course lasted 40 hours and was conducted on the basis of resolving reading guide’s in-house and referred discussion. Five instruments were applied: 1) critical reading including 108 items, 2) sub-group activities led by the professor, included 17 items, 3) student activities in sub-group discussions, with 18 items, 4) evaluation of the professor’s qualitative characteristics by the students that included 8 items and 5) a self-evaluation of the student tutor consisting of 10 items. Instruments 1, 2 and 4 were evaluated before and after the course. Instrument 1 was graded by adding the correct answers and subtracting those that were incorrect; medians were recorded. Both groups were compared with Mann Whitney U and Wilcoxon tests, statistical weight and randomness. A Likert scale was also used with values ranging from 1 (minimum) to 4 (maximum), in instruments 2 to 5; the values were added and medians were used. Consistency was determined in instruments 1 to 4.ResultsNo significant differences were detected between both groups in critical reading before and after the interventions, although statistical weight did increase and randomness decreased in G2 Instruments 2, 3 and 4 (Cronbach’s alpha > 0.75), reported adequate medians in almost all aspects; instrument 2 revealed almost maximum final results in G2. The tutors’ affection for students increased.DiscussionStudent tutors can develop complex teaching abilities and foster student learning. These strategies are underutilized in our milieu.

Introduccion La educacion medica actual busca el desarrollo de habilidades clinicas complejas, entre las que destaca por su relevancia, la aptitud clinica. Esta se define como la capacidad de tomar decisiones frente a un paciente particular en diferentes escenarios. Sin embargo, los reportes de instrumentos de medicion para medirla son escasos. Objetivo del estudio Construir y validar un instrumento para medir la aptitud clinica en el internado de pregrado (IP). Material y metodos Medicos becarios seleccionaron casos clinicos reales en las rotaciones del IP: urgencias (U), pediatria (P), medicina interna (MI), cirugia (CG), ginecoobstetricia (GO) y medicina familiar (MF). Seis profesores por rotacion, (hospitales publicos y privados) aprobaron los casos mas representativos. Instrumento: se seleccionaron cinco casos por rotacion. Se problematizaron en resumenes clinicos y se les agregaron tallos con reactivos que exploraban indicadores: factores de riesgo (FR), diagnostico (DX), paraclinicos (PCL), tratamiento (TX) y pronostico (PRN). Se cuidaron los aspectos ortograficos y de sintaxis, asi como las respuestas. Las opciones de respuesta fueron: cierto, falso. Una vez elaborados los resumenes y los reactivos, se sometio a la tecnica de Delphi, en dos rondas independientes, con los treinta y seis profesores. Durante la primera ronda se realizaron las adecuaciones sugeridas por ellos. Las respuestas se consideraron adecuadas cuando existio un acuerdo de 5/6 o 6/6 en las mismas. El instrumento se conformo finalmente con cinco casos (15 reactivos para cada caso) y 75 por modulo. Treinta casos y 450 reactivos en total; 66 para FR, 191 DX, 80 PCL, 86 TX y 27 PRN. Posteriormente se realizo una prueba piloto con alumnos del mismo nivel. Para calificarlo se elaboro un instrumento electronico para minimizar errores y facilitar su analisis. Se aplico a 30 alumnos que iniciaban el ciclo. Se obtuvo permiso para su aplicacion. Se procedio a analizar los resultados analizando medianas para cada caso e indicador por modulo. Se determino la consistencia por modulo y el azar de respuestas en niveles (azar, muy bajo, bajo, intermedio, alto, muy alto). Resultados Consistencia (Kuder-Richardson) por modulo de 0.63, 0.62, 0.63, 0.72, 0.70 y 0.45 para U, P, MI, CG, GO y MF, Las medianas obtenidas para ese mismo orden: 45, 35, 34, 27, 32, 41. Las medianas obtenidas por indicadores: FR 31, DX 99, PCL 37, TX 38 y PRN 15. La frecuencia mayor de alumnos en nivel alto fue en U e intermedio en MF y U. En CG la mayor frecuencia de muy bajo. Discusion La consistencia es adecuada, excepto en MF, pero se conserva para garantizar la validez de contenido. Las medianas por modulo se encuentran aproximadamente a la mitad y los indicadores tambien del maximo posible. La calificacion minima de un caso (endometriosis) fue 2 y la maxima 11 (neumonia) (de 15 posibles por caso). Comentario Se describe el proceso de validacion de un instrumento para medir la aptitud clinica. Los alumnos se encuentran a la mitad del maximo posible en modulo e indicadores. Instrumentos de evaluacion adecuados pueden otorgar una vision mas profunda del aprendizaje.