Implementation and results of a surgical training programme for chronic suppurative otitis media in Cambodia.

BACKGROUND: Chronic suppurative otitis media is a massive public health problem in numerous low- and middle-income countries. Unfortunately, few low- and middle-income countries can offer surgical therapy. METHODS: A six-month long programme in Cambodia focused on training local surgeons in type I tympanoplasty was instigated. Qualitative educational and quantitative surgical outcomes were evaluated in the 12 months following programme completion. A four-month long training programme in mastoidectomy and homograft ossiculoplasty was subsequently implemented, and the preliminary surgical and educational outcomes were reported. RESULTS: A total of 124 patients underwent tympanoplasty by the locally trained surgeons. Tympanic membrane closure at six weeks post-operation was 88.5 per cent. Pure tone audiometry at three months showed that 80.9 per cent of patients had improved hearing, with a mean gain of 17.1 dB. The trained surgeons reported high confidence in performing tympanoplasty. Early outcomes suggest the local surgeons can perform mastoidectomy and ossiculoplasty as safely as overseas-trained surgeons, with reported surgeon confidence reflecting these positive outcomes. CONCLUSION: The training programme has demonstrated success, as measured by surgeon confidence and operative outcomes. This approach can be emulated in other settings to help combat the global burden of chronic suppurative otitis media.

Transmission of visceral leishmaniasis in dogs in a risk area of the metropolitan region of Belo Horizonte, Minas Gerais, Brazil / Transmissão da leishmaniose visceral em cães em área de risco da Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil

Visceral leishmaniasis (VL) has spread rapidly across cities in the metropolitan region of Belo Horizonte. The aim of this study was to investigate VL dynamics in a prospective cohort study of dogs in Juatuba, between 2010 and 2011, to confirm the incidence of Leishmania infantum, and to assess possible risk factors associated with infection. An observational and prospective closed cohort study was performed using serology testing in dogs, randomly selected from the whole municipality. All seronegative dogs, or dogs with inconclusive results were monitored using indirect immunofluorescence (IIF) at 6-month intervals. The dog's owners completed a semi-structured questionnaire to assess possible causal factors of seroconversion, and the responses were assessed using logistic regression. The canine incidence coefficient was 206/1,000 dogs per year (CI: 178-238), and a cluster was identified in an area with a high concentration of seropositive dogs, but a low overall canine population. Large dogs were identified as a risk factor and the following variables were identified as protection factors: dogs aged over 4 years, daily peridomicile cleaning, and better socioeconomic conditions. VL is spreading over a large area in Juatuba in a short period of time.(AU)

A leishmaniose visceral (LV) expandiu-se de forma rápida e extensa pelos municípios da Região Metropolitana de Belo Horizonte. Objetivou-se estudar a dinâmica da LV em uma coorte prospectiva de cães em Juatuba, entre 2010 e 2011, para verificar a incidência e fatores de risco associados à infecção por Leishmania infantum. Foi feito um estudo observacional e prospectivo de coorte fechada por meio de análise sorológica em cães selecionados aleatoriamente em todo o município, com acompanhamento semestral dos resultados soronegativos e indeterminados na imunofluorescência indireta (IFI). Usou-se questionário semiestruturado junto aos proprietários de cães para avaliação da soroconversão e dos fatores determinantes a essa, por meio da regressão logística. O coeficiente de incidência canina foi de 206/1000 cães.ano (IC: 178 - 238), e foi identificado cluster em área com elevada concentração de cães soropositivos, mas com baixa densidade populacional canina. A variável cão de porte grande foi identificada como fator de risco, e as variáveis idade do cão superior a quatro anos, limpeza diária do peridomicílio e melhores condições socioeconômicas como fatores de proteção. A infecção por LV está ocorrendo em curto período de tempo e com ampla distribuição em Juatuba.(AU)

Avaliação de uma nova metodologia para a representação da pecuária no Brasil / Evaluation of a new methodology for the representation of livestock in Brazil

Na representação da pecuária municipal do Brasil, o uso de indicadores com valoração absoluta ou relativa pode gerar subestimação ou superestimação da produção. O tipo de dado utilizado pode ser influenciado por fatores quantitativos produtivos associados ao tamanho das áreas e não ao maior desenvolvimento da atividade. O presente estudo comparou três tipos de dados para a representação do perfil produtivo da pecuária leiteira: o percentual produtivo, a densidade produtiva e a eficiência quantitativa. Os municípios que lideraram a produção no percentual produtivo foram os de maior tamanho (52.460ha em pastagem) com alto número de vacas pouco produtivas; opostamente, na densidade produtiva, foram agrupados os de menor tamanho (8.084ha em pastagem) com poucas vacas de alta produção. A melhor representação foi para a eficiência quantitativa que agrupou municípios de tamanho intermediário (23.234ha em pastagem) com alto número de vacas de alta produção. A eficiência quantitativa constitui uma nova abordagem na representação da pecuária leiteira, sua aplicação integra os critérios quantidade e eficiência e reduz os problemas gerados pela alta variação no tamanho das áreas municipais.(AU)

In the municipality's livestock product representation in Brazil, the use of indicators with absolute or relative valuation can generate problems such as underestimation or overestimation. The type of data used can be influenced by the quantitative productive factors associated to the area's size and not to the further development of the activity. The present study compared three types of data for the representation of the productive profile of the dairy livestock in Brazil: the productive percentage, the productive density, and quantitative efficiency. The municipalities that led the production in the productive percentage were larger (52,460 ha in pasture), with a high number of low production cows; on the other hand, the productive density grouped the smaller (8,084 ha in pasture) with few high production cows. The best representation was for the quantitative efficiency that grouped municipalities of intermediate size (23,234 ha in pasture) with a high number of cows with high production. The quantitative efficiency constitutes a new approach for the representation of dairy farming, its application integrates the criteria quantity and efficiency, and reduces problems caused by the high variation in the size of the municipal areas.(AU)

Mapa do desenvolvimento da pecuária leiteira no estado de Minas Gerais, Brasil: nova abordagem na pecuária para integração espacial de variáveis produtivas / Map of the development of dairy husbandry in the state of Minas Gerais, Brazil: new approach to livestock for the spatial integration of production variables

Com base nos dados absolutos do Censo Agropecuário 2006, estruturou-se um sistema geográfico de informação e aplicou-se o método de análise multicritério para categorizar e avaliar o desenvolvimento da pecuária leiteira em Minas Gerais, Brasil. As variáveis selecionadas foram representadas espacialmente, classificadas e reclassificadas. Considerando-se seus pesos ponderados, foram combinadas por procedimentos de álgebra de mapas, em que se conformou o mapa com a caracterização do desenvolvimento leiteiro. Dos 853 municípios, 53 foram classificados como altamente desenvolvidos, 55 desenvolvidos, 229 moderadamente desenvolvidos, 500 pouco desenvolvidos e 16 não desenvolvidos. Encontrou-se associação entre o tamanho dos municípios e o desenvolvimento leiteiro; os de maior desenvolvimento tiveram área média de 175.414ha, e os de menor desenvolvimento apresentaram área média de 44.947ha. Esta abordagem para a integração espacial de dados censitários da pecuária possibilita uma nova forma de conhecer a realidade no seu desenvolvimento e promove sua aplicação em outros temas relacionados com a saúde e a produtividade animal...

Based on absolute data collected from the Agricultural census 2006 a Geographic Information System (GIS) and application of a multi-criteria analysis method to categorize and evaluate the development of dairy farming in Minas Gerais, Brazil. The selected variables were represented spatially, classified and reclassified; taking into account that their adjusted weights were combined by map algebra procedures, conforming the map with the characterization of the dairy development. Of the 853 municipalities, 53 were classified as highly developed, 55 developed, 229 moderately developed, 500 low development and 16 non-developed. Associations were found between the size of the municipalities and dairy development. The municipalities with greater development had an average area of 175.414 ha and those with lower development showed an average area of 44.947 ha. This approach with spatial integration of the livestock census data provides a powerful methodology to express the reality in its development and promotes this application in other topics related to animal health and productivity...

Procesos de evaluación del aprendizaje del cuidado en la práctica de estudiantes de Enfermería / Nursing students care practice learning assessment processes

Introducción: Esta investigación abordó la evaluación del aprendizaje del cuidado en la práctica de estudiantes de Enfermería en 2 universidades privadas de Bogotá, con programas de formación profesional de 10 semestres de duración. Objetivo: Analizar: ¿Cómo se está evaluando el aprendizaje del cuidado en la práctica de los estudiantes de Enfermería, de las Facultades de Enfermería de las Universidades A y B? Métodos: El diseño del estudio corresponde a una investigación evaluativa, empleando como muestra los 19 contenidos programáticos de las asignaturas del área de Enfermería y la participación de 42 docentes responsables de la práctica de las asignaturas de Enfermería en dichas instituciones. Para la recolección de la información se utilizaron dos formularios (para asignaturas y para docentes). Resultados: Se encontró que los resultados fueron muy similares en los 2 programas en relación al bajo número de competencias, elementos de competencias u objetivos de aprendizaje relacionados explícitamente con el conocimiento de cuidado de Enfermería como parte del componente disciplinar. El mayor número de competencias o elementos de competencias y objetivos de aprendizaje relacionados con el conocimiento del cuidado de Enfermería, coinciden en las asignaturas donde los docentes responsables de la práctica tenían una formación académica de Maestría en Enfermería. No se encontró un modelo de evaluación del aprendizaje del cuidado en la práctica, que oriente los procesos de enseñanza-aprendizaje y los retroalimente.

Introduction: This study addressed the evaluation of care practice learning among nursing students from 2 Bogota's private universities with professional formation programs of 10 semesters. Objective: The objective was to analyze: how care practice learning is being assessed among the students from the nursing faculties of universities A and B? Methods: The research design corresponds to an assessment study. Nineteen subject-contents and 42 academic staff were considered for the analysis. Data were gathered through a survey instrument for each group. Results: It was similar in both programs in relation to the low number of competencies or achieved learning objectives related to nursing care knowledge. The highest number of achieved competencies was found in program subjects offered by masters-level nursing teachers. A learning care practice evaluation model, which could orient the teaching-learning and feed-back processes, was not found.

Cytological features of ossifying fibromyxoid tumor of soft parts.

A case of ossifying fibromyxoid tumor (OFMT) evaluated during an intraoperative pathological consultation is presented. The patient, a 70-year-old woman was being followed because of a tumor in the left buttock. Cytological smears were obtained after scrapping the tumoral cut surface and revealed a myxoid background with fragments composed of a denser, fibrillar metachromatic stroma with accompanying round to oval tumoral nuclei and no vessels. Single cells were predominantly monomorphic with a round to oval morphology and scarce cytoplasm. The most relevant feature of the tumor was its peripheral, plaque-like, calcified consistency. The review of the cytological descriptions of four cases revealed similar findings that can be presumed as those of a low-grade myxoid tumor of round to oval cells. A specific recognition of OFMT based solely on cytological features seems difficult. However, when such features are coupled with characteristic radiological findings (peripheral calcification) this entity must be considered.

The role of magnetic resonance imaging in oncology

Conventional diagnostic magnetic resonance imaging (MRI) techniques have focused on improving the spatial resolution and image acquisition speed (whole-body MRI) or on new contrast agents. Most advances in MRI go beyond morphologic study to obtain functional and structural information in vivo about different physiological processes of tumor microenvironment, such as oxygenation levels, cellular proliferation, or tumor vascularization through MRI analysis of some characteristics: angiogenesis (perfusion MRI), metabolism (MRI spectroscopy), cellularity (diffusion-weighted MRI), lymph node function, or hypoxia [blood-oxygen-level-dependent (BOLD) MRI]. We discuss the contributions of different MRI techniques than must be integrated in oncologic patients to substantially advance tumor detection and characterization risk stratification, prognosis, predicting and monitoring response to treatment, and development of new drugs (AU)

Microbiological study of bulls of indulgence of the 15th-16th centuries.

During the restoration of the church of "San Esteban" in Cuéllar (Segovia, Spain) a few sepulchres were opened. Among them was that of Doña Isabel de Zuazo, from the 16th century. Together with the corpse was found a series of printed documents from the 15th-16th centuries, most of which were bulls of indulgence. A microbiological study of the documents was carried out using techniques of isolation and molecular microbiology, together with scanning electron microscopy. Most of the identified bacteria were highly suggestive of a human origin, particularly the predominance of Clostridium species consistent with the flora of the human intestinal tract. Our results demonstrate that appreciable post-mortem migration of bacteria has taken place from the corpse to the historic documents. This can be explained considering that the documents were found on pelvic region, and were contaminated by body fluids and putrefaction.

Accuracy of physical examination in subacromial impingement syndrome.

OBJECTIVE: Shoulder pain is a common complaint, frequently caused by subacromial impingement syndrome (SIS). There are a number of physical examination (PE) manoeuvres that explore the subacromial space. MRI provides an accurate anatomic image of the subacromial space, being the current gold standard in the diagnosis of SIS. The aim of this study is to evaluate the accuracy of the PE in the diagnosis of SIS and/or subacromial-subdeltoid bursitis (SSB) confirmed by MRI. METHODS: Consecutive outpatients with an episode of shoulder pain were prospectively included in the study. They were examined by a rheumatologist and, within 3 days, an MRI was done. Sensitivity, specificity, positive and negative predictive values, and accuracy of PE manoeuvres were calculated using a 2 x 2 table. RESULTS: Fourteen males and 16 females were included. All the tests exhibited acceptable sensitivity. As a result Yocum manoeuvre was considered the most sensitive and most accurate for SIS. With regard to SSB, the Gerber test was the most sensitive. The majority of the PE manoeuvres showed low specificity. CONCLUSIONS: Most PE manoeuvres identify reasonably well subacromial impingement of the shoulder, although, in general, they have low specificity. The Yocum test has the best sensitivity and precision. Our data suggest that imaging techniques should be recommended to better define shoulder lesions.

[Access to the internet among nurses and type of information sought]. / Acceso a internet de los profesionales de enfermería y tipo de consultas que realizan.

OBJECTIVE: To identify how nurses use the Internet through a survey performed in May 2005. METHOD: A descriptive cross-sectional study was performed. The information source was a survey sent electronically and through surface mail. The study population consisted of nursing professionals from distinct autonomous regions. RESULTS: The overall response rate was 40% (444 of 1,100). A total of 38.6% (184) of the nursing professionals used the Internet continually, especially men and nursing staff with a high level of English. The 5 most frequent reasons for surfing the net were searching for nursing literature (63% [264]), consulting the web pages of nursing journals (58.6% [256]), seeking information on drugs (55% [230]), seeking protocol manuals (50% [204]), and consulting the web pages of colleges of nursing (48). CONCLUSIONS: The behavior of nursing professionals is similar to that found among the general population in the "BBVA Foundation study of the Internet in Spain". Most nursing professionals are women. Male nursing professionals more frequently search for subjects related to nursing theory. Nurses use the Internet to search for nursing literature and consult journals, protocol manuals, and colleges of nursing, as well as to be familiar with the information aimed at patients.

Acceso a internet de los profesionales de enfermería y tipo de consultas que realizan / Access to the internet among nurses and type of information sought

Objetivo. Conocer el uso que los profesionales de enfermería hacen de internet, empleando un procedimiento por encuesta durante el mes de mayo de 2005. Método. Estudio descriptivo transversal que utiliza encuesta por correo postal y electrónico como fuente de información. La población de estudio ha sido profesionales de enfermería de diferentes comunidades autónomas. Resultados. La tasa global de respuesta ha sido del 40% (444 de 1.100). Utiliza internet de forma continua el 38,6% (184), y hay diferencias a favor de los varones y de los profesionales que dominan el inglés. Los 5 motivos más frecuentes son: búsqueda de literatura de enfermería 63% (264); consultar páginas de revistas de enfermería 58,6% (256); información acerca de fármacos 55% (230); manuales de protocolos 50% (204), y consultar páginas de colegios profesionales 48. Conclusiones. Los profesionales de enfermería tienen un comportamiento similar al encontrado en población general en "el estudio de la Fundación BBVA sobre Internet en España". La enfermería es una profesión mayoritariamente desempeñada por mujeres. Los temas que constituyen el desarrollo teórico de nuestra disciplina se consultan con mayor frecuencia por los varones. Se accede a internet para buscar literatura de enfermería, consultar revistas, manuales de protocolos, consultar colegios profesionales y para conocer la información que circula en la red dirigida a los pacientes

Objective. To identify how nurses use the Internet through a survey performed in May 2005. Method. A descriptive cross-sectional study was performed. The information source was a survey sent electronically and through surface mail. The study population consisted of nursing professionals from distinct autonomous regions. Results. The overall response rate was 40% (444 of 1,100). A total of 38.6% (184) of the nursing professionals used the Internet continually, especially men and nursing staff with a high level of English. The 5 most frequent reasons for surfing the net were searching for nursing literature (63% [264]), consulting the web pages of nursing journals (58.6% [256]), seeking information on drugs (55% [230]), seeking protocol manuals (50% [204]), and consulting the web pages of colleges of nursing (48). Conclusions. The behavior of nursing professionals is similar to that found among the general population in the "BBVA Foundation study of the Internet in Spain". Most nursing professionals are women. Male nursing professionals more frequently search for subjects related to nursing theory. Nurses use the Internet to search for nursing literature and consult journals, protocol manuals, and colleges of nursing, as well as to be familiar with the information aimed at patients

[Prevalence of hiatal hernia and chronic esophagitis in adult asthmatic patients]. / Prevalencia de hernia hiatal y esofagitis crónica en pacientes asmáticos adultos.

BACKGROUND: The association among asthma, hiatus hernia, oesophagitis and gastro-oesophageal reflux has been reported as etiologic factor that alters the clinical evolution of the asthma. MATERIAL AND METHODS: Prospective, longitudinal and comparative study was developed. 90 patients were incoming with persistent light and moderate asthma, of allergic etiology. By the 6 months of immune-allergic treatment the clinical answer was valued being classified in two groups: Group A: 40 patients with intermittent light asthma and group B: 50 patients with persistent severe moderate asthma. In both groups they were submitted to an endoscopy for the diagnosis of esophageal pathology, with biopsies in the 3 esophageal thirds. They registered symptoms of gastro-oesophageal reflux. RESULTS: 72 women and 28 men, age average 35.9 years. There was hiatus hernia in 33 patients, 12 of the group A and 21 of the B. Upper oesophagitis in 21 patients, 8 of the group A and 13 of the B. Symptoms of gastro-oesophageal reflux in 71 patients, 29 of the group A and 42 of the B. The association among hiatus hernia, oesophagitis and gastro-oesophageal reflux was observed in 12 patients, 2 of the group A and 10 of the B (p < 0.05). CONCLUSIONS: The association of symptoms among gastro-oesophageal reflux, hiatus hernia and upper oesophagitis, is bigger in the patients with bad answer to the anti-asthmatic treatment; they are justified to endoscopy study and biopsies of the upper oesophagus (in the group of patients with bad response and symptoms of gastro-oesophageal reflux) when 24 hours pH-monitoring is not available.

Apoyo social, actividad y salud en ancianos / Social support, activity, and health among the elderly

The present study examined the relationship between social support, activity level and physical health among a sample of 96 Puerto Rican elderly persons. The Spanish version of the Inventory of Socially Supportive Behaviors (ISSB28) was used to assess social support. Two structured questionnaires were administered to obtain measures of activity level and physical health. A multiple correlation-regression analysis was performed, and partial correlation coefficients were also obtained. A partial correlation of .48 (p < .001) was observed between the ISSB scores and the measure of physical health, indicating a direct relationship between poor health and social support. This finding is inconsistent with previous studies, which suggest that better health is associated with higher levels of social support. Moderate-low, negative correlations were found between activity level and 3 indicators of poor health. Thus, higher activity levels were associated with better physical health. For example, partial correlations of-.31 (p = .003) and -.29 (p = .007), respectively, were found between the activity level and the number and length of hospital stays. The correlation between the amount of surgical interventions undergone by the patient during the previous year and the activity level was -.28 (p = .009). These findings demonstrate that higher levels of activity are associated with better physical health in elderly persons, as indicated by less frequent and shorter hospital stays, and lower frequency of surgical interventions. Several multiple regression analyses showed that social support and activity level, taken together, are statistically significant predictors of the number and length of hospital stays, and the number of surgical interventions undergone by the elderly patient. Together, these two factors explain from 11 to 18% of the variability in several indicators of physical health

[Treatment of Paget's disease with olpadronate. Its efficacy in partial responders to oral pamidronate]. / Tratamiento de la enfermedad de Paget con olpadronato. Su eficacia terapéutica en respondedores parciales al pamidronato oral.

Bisphosphonates are the treatment of choice in patients with Paget's disease. However in patients with an extensive disease it has been difficult to achieve complete biochemical remission. We studied the efficacy of the new bisphosphonate: olpadronate (dimethyl APD) in 37 patients (21 men and 16 women) with Paget's disease of (mean +/- 1SD) 68 +/- 8 years of age: Group I: 12 patients without previous specific treatment. Group II: 25 patients who had been treated before (time free of treatment before olpadronate: 11 +/- 8 months). (Table 1). Olpadronate was given orally in doses of 100 to 200 mg/day. Initial dose and/or increment of the dose during treatment were decided accordingly to the biochemical response. The length of therapy was (mean +/- 1SD) 3.5 +/- 2.4 months (range 0.5-13 months) and was adjusted to the changes produced upon the biochemical indexes of bone turnover. Olpadronate was well tolerated by all the patients except for one who discontinued the treatment due to gastrointestinal symptoms. Mean alkaline phosphatase (APh) decreased in both groups of patients as follows: Group I: basal: 36 +/- 20 KAU, final: 12 +/- 3 KAU (normal range: 5 to 15 KA units) and group II: basal 45 +/- 30 KAU final 14 +/- 10 KAU. (Table 2). Normalization of APh was observed in all patients of group I and in 21/25 patients of group II. Three patients of group II had partial responses (60% of diminution of APh without reaching normal values) and treatment was not effective in 1 patient. The length of remission was 8.7 +/- 5.7 months in group I and 10.4 +/- 8.1 months in group II. There was a significant inverse correlation between duration of remission and APh level post treatment. Fourteen patients of group II (7 women and 7 men) had previously received oral pamidronate (APD) in different cycles during a period of 6.6 +/- 4.2 years. After the first APD cycle, only 2 out of 14 achieved normal APh values and none of the 14 achieved complete biochemical remission after the last APD cycle. Olpadronate caused a significant decrease of serum APh and THP compared to the lowest values observed during APD treatment. Normalization of APh was observed in 12/14 of these partial responders to APD. (Table 3 and Figure 1). In conclusion, oral Olpadronate in a dose of 100 to 200 mg was well tolerated and effective in the treatment of Paget's disease even in those previous partial responders to APD.

[Social support, activity, and health among the elderly]. / Apoyo social, actividad y salud en ancianos.

The present study examined the relationship between social support, activity level and physical health among a sample of 96 Puerto Rican elderly persons. The Spanish version of the Inventory of Socially Supportive Behaviors (ISSB28) was used to assess social support. Two structured questionnaires were administered to obtain measures of activity level and physical health. A multiple correlation-regression analysis was performed, and partial correlation coefficients were also obtained. A partial correlation of .48 (p < .001) was observed between the ISSB scores and the measure of physical health, indicating a direct relationship between poor health and social support. This finding is inconsistent with previous studies, which suggest that better health is associated with higher levels of social support. Moderate-low, negative correlations were found between activity level and 3 indicators of poor health. Thus, higher activity levels were associated with better physical health. For example, partial correlations of-.31 (p = .003) and -.29 (p = .007), respectively, were found between the activity level and the number and length of hospital stays. The correlation between the amount of surgical interventions undergone by the patient during the previous year and the activity level was -.28 (p = .009). These findings demonstrate that higher levels of activity are associated with better physical health in elderly persons, as indicated by less frequent and shorter hospital stays, and lower frequency of surgical interventions. Several multiple regression analyses showed that social support and activity level, taken together, are statistically significant predictors of the number and length of hospital stays, and the number of surgical interventions undergone by the elderly patient. Together, these two factors explain from 11 to 18% of the variability in several indicators of physical health.

[A prospective study of programmed nursing consultation in an urban health center]. / Estudio prospectivo de la consulta programada de enfermería en un centro de salud urbano.

A study of the programmed nurse clinic in a health center was carried out to evaluate its different health care activities, the time consumed in them, the type of patients cared for, and the mechanism of organization of the clinic. A remarkable finding was a high number of daily appointments (11.8 persons), with an excellent rate of compliance with the appointment (89.3%). It was found that most of the diseases cared for in the nurse clinic were those most commonly managed with a protocol design in primary care: hypertension (34.1%), diabetes (6.9%), hyperlipoproteinemia (9%) and obesity (12.8%). Other parameters were evaluated, such as mean time per visit, which was predominantly between five and ten minutes, or activities during the visits, with a clear predominance of the clinical protocols. There was a remarkably high efficiency of the nursing staff, with a low rate of referral to the medical clinic (6.9%). We conclude that nurse clinics play an important role in the health centers, as the only possible mechanism to guarantee the correct fulfillment of the different programs. This requires a definite constant physical space for a given minimal period of time of about 2 hours per day.