The impact of the COVID-19 pandemic on medical education: adaptability and remote learning experience of the Peruvian American Medical Society

The COVID-19 pandemic had a significant impact on medical care and medical education in Peru. In response, the Peruvian American Medical Society (PAMS), a charitable medical organization based in the USA, pursued its medical and educational missions in Peru by adopting virtual learning technology. We developed closer collaborative relationships with several medical schools and the Peruvian Association of Medical Schools (ASPEFAM) while offering a faculty panel of twenty-four members to provide lectures and multidisciplinary webinars in Spanish. We conducted 19 webinars including COVID -19 and non-COVID-19 related topics that over the last two years attracted 14,489 participants from 23 countries. They were the foundation for twenty publications in Peruvian medical journals. Our clinical investigations competition was positively received as was our pilot project on research mentorship. The COVID -19 pandemic had a positive effect on the educational mission of PAMS in Peru.

First isolation and characterization of the prototype strain of the SARSCoV-2 virus at the beginning of the COVID-19 pandemic in Peru

Introduction: Currently, isolated from SARS-CoV-2 virus exceed 600 million cases in the world. Objective(s): Isolation and characterization of the SARS-CoV-2 virus causing COVID-19 at the beginning of the pandemic in Peru. Method(s): Twenty nasal and pharyngeal swab samples were isolated from SARS-CoV-2 using two cell lines, Vero ATCC CCL-81 and Vero E-6;virus identification was performed by RT-PCR and the onset of cytopathic effect (CPE) was evaluated by indirect immunofluorescence and subsequent identification by genomic sequencing. One of the most widely circulating isolates were selected and named the prototype strain (PE/B.1.1/28549/2020). Then 10 successive passages were performed on Vero ATCC CCL-81 cells to assess mutation dynamics. Result(s): Results detected 11 virus isolates by cytopathic effect, and subsequently confirmed by RT-PCR and indirect immunofluorescence. Of these, six were sequenced and identified as the lineages B.1, B.1.1, B.1.1.1, and B.1.205 according to the Pango lineage nomenclature. The prototype strain corresponded to lineage B.1.1. The analysis of the strains from the successive passages showed mutations mainly at in the spike (S) protein of the virus without variation in the identity of the lineage. Conclusion(s): Four lineages were isolated in the Vero ATCC CCL-81 cell line. Subcultures in the same cell line showed mutations in the spike protein indicating greater adaptability to the host cell and variation in pathogenicity in vitro, a behavior that allows it to have more survival success.Copyright © 2023 Anales de la Facultad de Medicina. All rights reserved.

Successful Inter-Professional Team (IPT) collaboration in the care of peripartum women with COVID-19 on Extracorporeal Membrane Oxygenation (ECMO)

Objectives: To describe the IPT collaborative approach for peripartum women with COVID-19 on ECMO and report the intervention outcomes. Method(s): A retrospective electronic health record review was performed from January 2020 through January 2022. All peripartum women on ECMO with COVID19 admitted to the cardiothoracic intensive care unit (CTICU) were included. The IPT came together to coordinate peripartum care and delivery. An algorithm was created to outline the roles and workflow in the care of these patients. The outcomes evaluated included delivery method, timing, and location, maternal survival at discharge, maternal ICU length of stay (LOS), and neonatal survival Results: Thirteen Peropartum women were placed on ECMO (5 antepartum and 8 postpartum, ages 27-42). None had been vaccinated against COVID-19. All received femoral vessel cannulation (11 venovenous and 2 venoarterial). Four patients underwent Caesareansection delivery while on ECMO. Maternal survival to hospital discharge was 84.6%. All neonates survived with COVID-19 negative status. Conclusion(s): The collaborative IPT approach with a structured algorithm facilitated survival outcomes. This report adds to the limited literature on peripartum. ECMO and provides insights to consider in planning for the care of these patients.

Structure-Based Discovery of Inhibitors of the SARS-CoV-2 Nsp14 N7-Methyltransferase.

An under-explored target for SARS-CoV-2 is the S-adenosyl methionine (SAM)-dependent methyltransferase Nsp14, which methylates the N7-guanosine of viral RNA at the 5'-end, allowing the virus to evade host immune response. We sought new Nsp14 inhibitors with three large library docking strategies. First, up to 1.1 billion lead-like molecules were docked against the enzyme's SAM site, leading to three inhibitors with IC50 values from 6 to 50 µM. Second, docking a library of 16 million fragments revealed 9 new inhibitors with IC50 values from 12 to 341 µM. Third, docking a library of 25 million electrophiles to covalently modify Cys387 revealed 7 inhibitors with IC50 values from 3.5 to 39 µM. Overall, 32 inhibitors encompassing 11 chemotypes had IC50 values < 50 µM and 5 inhibitors in 4 chemotypes had IC50 values < 10 µM. These molecules are among the first non-SAM-like inhibitors of Nsp14, providing starting points for future optimization.

Role of Hologic® Panther AptimaTM SARS-CoV-2 assay in the detection of SARS-CoV-2: screening or diagnostic technique?

During the multiple waves of COVID-19 suffered all over the world, having a rapid and sensitive diagnostic test has become a priority for microbiology laboratories. The AptimaTM SARS-CoV-2 transcription-mediated amplification (TMA) assay running on the Panther system (Hologic) was presented as a very good option to cover this need. To evaluate this system, 570 respiratory samples were included in the study and were processed both by the Panther (Hologic) system and by qRT-PCR (Thermo Fisher Science, Waltham, USA), current assay for the diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A high number of false positives (n=76) was obtained with Panther system (Hologic), but the number of false positives decreases as the relative light units (RLU) value increases. These results show that this technique can be a good option for sample screening but checking for positive results should be mandatory, especially those with low RLU values.

Cuban Vaccines Abdala and Mambisa against Covid-19

Intro: With the first case of COVID-19 in Cuba on March 11, 2020, the Center for Genetic Engineering and Biotechnology in Havana began an extensive vaccine program. Two vaccines based on RBD recombinant protein were developed, one for systemic administration "Abdala" and one mucosal vaccine "Mambisa". Abdala received the EUA in July 2021 and "Mambisa" completed its clinical development as a booster dose for convalescent subjects. Method(s): Two doses (25 and 50 microg) and two schedules (0-14-28 and 1-28-56 days) were evaluated in phase I clinical trials with volunteers 19 to 54 years old. The phase II and III clinical trials were also double-blind, randomized, and placebo-controlled, and included respectively 660 and 48,000 volunteers from 19 to 80 years. The anti-RBD titers were evaluated using a quantitative ELISA system developed at the Center for Immunoassay, Havana Cuba, and ELECSYS system from Roche. The RBD to ACE2 plate-based binding competitive ELISA was performed to determine the inhibitory activity of the anti-RBD polyclonal sera on the binding of the hFc-ACE2 coated plates. The neutralization antibody titers were detected by a traditional virus microneutralization assay (MN50). Finding(s): The Abdala vaccine reached 92.28% efficacy. The epidemic was frankly under control in Cuba after the vaccine introduction having reached the highest levels of cases and mortality in July 2021 with the dominance of the Delta strain. The peak of the Omicron wave, unlike other countries, did not reach half of the cases of the Delta wave with a significant reduction in mortality. The mucosal vaccine candidate "Mambisa" completed its clinical development as a booster dose for convalescent subjects reaching the trial end-point. Conclusion(s): Vaccine composition based on RBD recombinant antigen alone is sufficient to achieve high vaccine efficacy comparable to mRNA and live vaccine platforms. The vaccine also protects against different viral variants including Delta and Omicron strains.Copyright © 2023

Analysis of paxlovid® for the treatment of COVID-19 in Aragón, Spain

Background and ImportancePaxlovid® is indicated for the treatment of COVID-19 in adults who do not require supplemental oxygen and who are at increased risk for progressing to severe COVID-19. The Spanish Drug Agency published prioritisation criteria for it access. Paxlovid® has significant drug interactions, mainly due to ritonavir. Hospital pharmacists must validate the prescription, carrying out a thorough review of the patient‘s medical history to check its suitability, as well as the concomitant medication to avoid interactions.Aim and ObjectivesAnalyse the use of Paxlovid® in Huesca and Sector-1 of Zaragoza (Aragon, Spain) in early months post-authorisation.Material and MethodsAll Paxlovid's prescriptions from April to September 2022 were reviewed. The following variables were collected: gender, age, vaccination schedule, prioritised high-risk criteria and renal function. All concomitant medication was reviewed for drug interactions using a protocol created by Coordination Unit for the Rational Drug Use of Aragon. The observations made to the prescribing physician by the hospital pharmacist were recorded.Results40 requests were received. 5 were prescription errors. 29 (82.9%) were accepted and 6 (17.1%) rejected. Median age (years, interquartile-range q1-q3) was 52.2 (45.6–65.3), 57.1% were male. Vaccination status was complete primary vaccination with booster-dose (62.8%) followed by complete vaccination (25.7%) and incomplete vaccination (11.5%). As high-risk criteria prioritised, 91.4% belonged to group composed by immunocompromised persons. 91.4% had renal function >60ml/min. Only in 3 cases (8.6%) the prescribing physician indicated the patient had potential drug interactions.All patients had concomitant medication, median of 8 drugs (4–10). 60% had any potential interaction, with serious drug interactions in 42.9% of them. Drugs with potential serious interactions were statins (5/11);benzodiazepines (2/11) and antithrombotic agents (2/11).44.8% prescriptions were accepted with recommendations to modify or temporary stop some of the patient‘s usual treatment. 80% of the rejected cases were due to serious drug interactions.Conclusion and RelevanceIn the use of Paxlovid®, the role of hospital pharmacists was crucial, as drug interactions were detected in 60% of patients and were serious in 42.9% of them, leading to recommendations for adjustments in patients‘ drug therapy in almost half of the cases, with potentially serious drug interactions being the main reason to not dispense Paxlovid®.References and/or AcknowledgementsConflict of InterestNo conflict of interest

[Risk of thrombosis recurrence among patients with COVID-19- and surgery-associated venous thromboembolism]. / Riesgo de recurrencia de la trombosis en pacientes con tromboembolia venosa asociada a COVID-19 y a cirugía.

Introduction: Recent surgery is a well-known major transient risk factor for venous thromboembolism (VTE) due to the low risk of VTE recurrence after anticoagulation is discontinued. On the other hand, the risk of VTE recurrence among patients with COVID-19-associated VTE is unknown. This study aimed to compare the risk of VTE recurrence between patients with COVID-19- and surgery-associated VTE. Methods: A prospective observational single-center study was performed including consecutive patients diagnosed with VTE in a tertiary hospital from January 2020 to May 2022 and followed up for at least 90 days. Baseline characteristics, clinical presentation, and outcomes were assessed. The incidence of VTE recurrence, bleeding, and death was compared between both groups. Results: A total of 344 patients were included in the study: 111 patients with surgery-associated VTE and 233 patients with COVID-19-associated VTE. Patients with COVID-19-associated VTE were more frequently men (65.7% vs 48.6%, p = 0.003). VTE recurrence was 3% among COVID-19 patients and 5.4% among surgical patients, with no significant differences (p = 0.364). The incidence rate of recurrent VTE was 1.25 per 1000 person-months in COVID-19 patients and 2.29 person-months in surgical patients, without significant differences (p = 0.29). In the multivariate analysis, COVID-19 was associated with higher mortality (HR 2.34; 95% CI 1.19-4.58), but not with a higher risk of recurrence (HR 0.52; 95% CI 0.17-1.61). No differences were found in recurrence in the multivariate competing risk analysis (SHR 0.82; 95% CI 0.40 - 2.05). Conclusions: In patients with COVID-19 and surgery-associated VTE, the risk of recurrence was low, with no differences between both groups.

Performance in distance work and telework modalities in Cuba from a gender perspective

In Cuba, the implementation of telework and distance work has expanded with the arrival of the Covid-19 pandemic. This happened in atypical confinement conditions in the family home, that leads to greater overload for women remote workers, due to the traditional gender roles. This paper discusses the results of the national study on distance work / telework seen from a gender perspective, that show the inequalities that these modalities have on men and women. The need of this approach is confirmed if a more equitable, inclusive and healthy work environment is to achieved for all.

Pneumocystis jirovecii and methicillin-resistant Staphylococcus aureus superinfection, a challenge in a post-COVID-19 scenario

We present a case of an 87-year-old nonsmoker female who recovered after infection by SARS-CoV-2 and was readmitted two weeks later due to respiratory sepsis. Radiological imaging showed a significant radiological worsening with extensive areas of bronchopneumonia and ground-glass opacities suggestive of organizing pneumonia. Empirical treatment with meropenem 1g/8h was started;however, clinical worsening persisted with tachypnea and desaturation requiring heated high-flow nasal cannula oxygen therapy, with poor response. Methicillin-resistant Staphylococcus aureus was isolated both in nasal screening swab and sputum, and RNA polymerase chain reaction in induced sputum was positive for P. jirovecii. Serum (1-3)-beta-D-glucan was normal, and blood cultures were sterile. Antibiotic therapy was adjusted with intravenous linezolid 600mg/12h and trimethoprim-sulfamethoxazole 320/1600mg/6h, plus methylprednisolone 40mg/day. Unfortunately, the patient had no response to optimized treatment and finally died. Clinicians should be aware of opportunistic and resistant microorganisms superinfections in relation to SARS-CoV-2 infection, even more, when corticosteroids are widely used.

[Expert opinion on strategies to improve vaccination coverage against seasonal influenza]. / Documento de opinión de expertos para la mejora de la cobertura vacunal frente a la gripe estacional.

Seasonal flu continues to be a major public health concern, and the influenza vaccine remains the most effective preventive measure. In Spain, vaccination coverage data from previous seasons show vaccination rates well below official targets; however, these figures improved significantly after the COVID-19 pandemic. Given the importance of achieving and maintaining high vaccination rates in order to avoid the clinical and economic impact of influenza, our multidisciplinary group of experts on vaccines analyzed the impact of low vaccination rates in Spain and drafted a series of measures to boost influenza vaccination coverage, particularly among priority groups.

Analysis of mortality in an Intermediate Respiratory Care Unit (ICRU)

Introduction The development of non-invasive mechanical ventilation (NIMV), its scientific evidence and the need to monitor the most severe cases, has led to the creation of the IRCUs. In our hospital, we apply NIMV to patients with acute respiratory failure (ARF) or exacerbated chronic respiratory failure (ACRF). Material and methods Prospective study of 220 non-Covid patients with ARF or ACRF who require NIMV and admission to the IRCU. General clinical and radiological data were collected and mortality was analyzed, as well as compared with the year 2019, when we did not have an IRCU. Results Mean age 71 years, (56 % men) and a Charlson Index (mean) of 6.4 points. The most frequent respiratory failure was hypercapnic 65 % vs. hypoxemic 34 %. After IRCU, 77 % were referred to the ward, 5 % to the Intensive Care Unit (ICU), and 17 % died or began comfort measures. Mortality in the IRCU is significantly related to the data in the table. There are 12 % of patients who, having been discharged from the IRCU, finally die during the rest of their hospital stay. Of these, 3 % are deaths of those admitted to the ICU, and 9 % to deaths on the ward after discharge from the IRCU. Analyzing mortality, we found significant differences in terms of the service they belong to (Internal Medicine 41 %), hypoxemic failure (58 %), bilateral infiltrates (52 %), age (80 years) and Charlson Index (7.8) (*Tab. 1). Finally, we have compared mortality in the IRCU with that of 2019 when we did not have this Unit, using the hospital mortality data (not mortality in the IRCU as it was not available in 2019). For this, we have amnalyzed a representative saple of 53 % of the most severe cases treated in 2019 with NIMV in the ward, according to Apache II, and which was similar in age and comorbidities to those admitted to the IRCU. **Without IRCU: Age 70.6 years // Charlson 6.4 // ICU admission 15 % // Hospital mortality 38 %. **With IRCU: Age 71 years // Charlson 6.4 // ICU admission 5 % // Hospital mortality 29 % Conclusions Mortality is higher in hypoxemics, related to Charlson Index and infiltrates. The opening of the IRCU has led to a decrease in hospital mortality for severe patients who require NIMV, and a 66 % decrease in ICU admissions.

Riesgo de recurrencia de la trombosis en pacientes con tromboembolia venosa asociada a COVID-19 y a cirugía Risk of thrombosis recurrence among patients with COVID-19- and surgery-associated venous thromboembolism

Introducción La cirugía reciente es un factor de riesgo transitorio mayor y conocido de tromboembolia venosa (TEV) debido al bajo riesgo de recurrencia de la TEV una vez suspendida la anticoagulación. Por otro lado, se desconoce el riesgo de recurrencia de la TEV en los pacientes con TEV asociada a COVID-19. El objetivo de este estudio consistió en comparar el riesgo de recurrencia de la TEV entre pacientes con TEV asociada a COVID-19 y a cirugía. Métodos Se realizó un estudio prospectivo, observacional y unicéntrico en el que participaron pacientes consecutivos diagnosticados de TEV en un hospital terciario entre enero de 2020 y mayo de 2022 y que fueron objeto de seguimiento durante un mínimo de 90 días. Se evaluaron las características iniciales, el cuadro clínico y los resultados clínicos. Se compararon las incidencias de recurrencia de la TEV, hemorragias y muertes entre ambos grupos. Resultados En el estudio se incluyó a un total de 344 pacientes: 111 con TEV asociada a cirugía y 233 con TEV asociada a COVID-19. Entre los pacientes con TEV asociada a COVID-19 hubo una mayor frecuencia de varones (65,7 vs. 48,6%, p = 0,003). La recurrencia de la TEV fue de 3% en los pacientes con COVID-19 y de 5,4% en los pacientes quirúrgicos, sin diferencias significativas (p = 0,364). La tasa de incidencia de TEV recurrente fue de 1,25 y 2,29 por 1.000 personas-meses en los pacientes con COVID-19 y quirúrgicos, respectivamente, sin diferencias significativas (p = 0,29). En el análisis multifactorial, la COVID-19 se asoció a una mayor mortalidad (HR = 2,34;IC 95%, 1,19-4,58), pero no a un mayor riesgo de recurrencia (HR = 0,52;IC 95%, 0,17-1,61). En el análisis multifactorial de riesgos competitivos no se observaron diferencias en cuanto a recurrencias (SHR = 0,82;IC 95%, 0,40-2,05). Conclusiones El riesgo de recurrencia fue bajo en los pacientes con TEV asociada a COVID-19 y a cirugía, sin diferencias entre ambos grupos.

Densely Connected Neural Network and Permutation Entropy in the Early Diagnostic in COVID Patients

The COVID-19 pandemic has been characterized by the high number of infected cases due to its rapid spread around the world, with more than 6 million of deaths. Given that we are all at risk of acquiring this disease and that vaccines do not completely stop its spread, it is necessary to continue proposing tools that help mitigate it. This is the reason why it is ideal to develop a method for early detection of the disease, for which this work uses the Stanford University database to classify patients with SARS-CoV-2, also commonly called as COVID-19, and healthy ones. In order to do that we used a densely connected neural network on a total of 77 statistical features, including permutation entropy, that were contrasted from two different time windows, extracted from the heart rate of 24 COVID patients and 24 healthy people. The results of the classification process reached an accuracy of 86.67% and 100% of precision with the additional parameters of recall and F1-score being 80% and 88.89% respectively. Finally, from the ROC curve for this classification model it could be calculated an AUC of 0.982. © 2022 Creative Commons.

Mobile banking service quality and consumer loyalty

The Covid-19 pandemic forced people and entities to adopt measures to protect themselves from contagion by resorting to the use of digital media, as was the case in banking. The purpose of this research was to determine the relationship between the quality of mobile banking service and consumer loyalty in Peru. The methodology was mixed approach. In the quantitative aspect, with a sample of 383 users of banking entities in Comas, Lima, a survey was applied, with a reliability of the instrument of 0.912. In the qualitative aspect, seven experts were interviewed whose opinions were contrasted with the theoretical information developed. The results of the survey indicated that there is a correlation with a preferred position with a tendency to be strong among the study variables (Spearman's Rho of 0.796). Likewise, the experts indicated that mobile banking has managed to retain the majority of users due to the speed and security of the service. In conclusion, it was evidenced that there is a preferential relationship with a tendency to be strong between the variables under study, based on a relative trust and security of the user, making it necessary to offer quality services using various communication mechanisms. © 2023, Universidad del Zulia. All rights reserved.

Not Every Day is Monday for Employees Confined due to COVID-19: Anticipatory Happiness Matters

This study focuses on anticipatory happiness during the week (current happiness but considering the rest of the week) in employees confined due to COVID-19. In Diary Study 1, 71 employees with home-based telework participated on five consecutive workdays (Monday-Friday). We found a quadratic change pattern with an acceleration of the increase in anticipatory happiness right before the weekend. Results also confirmed a positive association between daily variability in anticipatory happiness and daily fluctuations in job satisfaction and positive affect. In Diary Study 2, 83 employees who carried out an essential activity outside the home participated for two consecutive weeks. Our findings showed a cubic change pattern where anticipatory happiness reaches its highest average score on Friday, dropping sharply on Monday, and then the cycle (rhythm) begins again. Changes in anticipatory happiness were positively associated with changes in job satisfaction and positive affect, and negatively related to fluctuations in negative affect. © 2022 Colegio Oficial de Psicologos de Madrid. All rights reserved.

Identifying gaps and redesigning asthma care pathway in Primary Care with multidisciplinary teams

1. Introduction: Asthma causes significant morbidity and mortality worldwide. COVID-19 scenario has revealed lacks in the current model of asthma management in Primary Care (PC). 2. Aims and objectives: The aim was to build a reference framework and address patients' needs to help asthma management improvement in a COVID-19 scenario. 3. Method(s): A scientific committee from the Spanish Respiratory Group in PC (GRAP) defined an evidence-based gold standard model for asthma care pathway including: suspected asthma, confirmed asthma, asthma follow-up, asthma exacerbations and special situations in asthma. Multidisciplinary teams (family doctors, PC nurses, practice clerks, and community pharmacists) were recruited from 17 PC settings in 7 Spanish regions to characterise their local asthma care pathway and to identify room for improvement in different areas according to previously defined gold-standards. A national online Digital Innovation Laboratory was held with representatives of the local teams to prioritise areas of improvement in terms of clinical impact and to co-design action plans. 4. Result(s): 43 to-be-improved areas in asthma care pathways were identified, classified into different categories. Continuing care, collaborative work between Primary and Secondary care, availability of qualified healthcare staff, data recording and management, digital transformation and patient empowerment were some of the areas to prioritize. 5. Conclusion(s): Multidisciplinary pre-structured team work with Digital Innovation Laboratory support could help to redesign the asthma patient's pathway and to improve the effective asthma management in a COVID-19 scenario.

Digital Habits of Users in the Post-Pandemic Context: A Study on the Transition of Mexican Internet and Media Users from the Monterrey Metropolitan Area

The COVID-19 pandemic accelerated the transformation of digital interactions, a development that has been growing in the last decade. Digital platforms have become indispensable in the institutional communication of public and private organizations. The magnitude of this change was evident during the pandemic at a time when several countries implemented social distancing measures to contain the contagion. This situation caused a certain degree of user dependence on information and communication technologies. The objective of this research is to analyze the time of use, the changes, and habits of digital consumption at the beginning and during the COVID-19 pandemic in the metropolitan area of Monterrey, Nuevo León, Mexico. Access to both social networks and digital entertainment platforms was examined during the period in which Internet users had resumed a large part of face-to-face activities, and 1500 questionnaires were conducted considering the current data of the population of the urban area according to what was reported by the INEGI (National Institute of Statistics and Geography). The results indicate that after COVID-19, a digital transformation was accelerated, and, in that period, social media helped to build trust according to the users consulted in the Monterrey metropolitan area. However, trust was given at an interpersonal level due to motivations such as the prior user relationships in offline spaces and not so much because of the institutional campaigns that were behind the digital transformation. © 2023 by the authors.

TEACHING BELIEFS ON THE CURRICULAR INTEGRATIONS OF ICT IN RELIGIOUS EDUCATION IN PERU

This study is part of a doctoral research that seeks to relate teaching beliefs and socioemotional competencies of elementary school teachers. This is relevant given the absence of studies of this type in Peruvian contexts in religious education and the need for changes in the curricular systems produced by Covid-19. For this purpose, a comparative correlational study was carried out with the objective of identifying the types of existing beliefs and how sex, age and years of service have an impact on the configuration of the beliefs of religion teachers. A total of 303 teachers from Lima-Peru participated. The Teaching Beliefs Questionnaire (CCRED) was used to assess value, competence and pedagogical beliefs. The results indicate that value beliefs predominate among teachers, followed by pedagogical and competence beliefs. It was also found that age and years of service are predictor variables of the establishment of beliefs, as opposed to sex. It is considered that this work contributes to deepen in fundamental variables for ICT training and to improve educational practice in post-pandemic contexts. © 2023, University of Cienfuegos, Carlos Rafael Rodriguez. All rights reserved.