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BACKGROUND: Gut microbiota and its by-products are increasingly recognized as having a decisive role in cardiovascular diseases. The aim is to study the relationship between gut microbiota and early vascular ageing (EVA). METHODS: A cross-sectional study was developed in Salamanca (Spain) in which 180 subjects aged 45-74 years were recruited. EVA was defined by the presence of at least one of the following: carotid-femoral pulse wave velocity (cf-PWV), cardio-ankle vascular index (CAVI) or brachial-ankle pulse wave velocity (ba-PWV) above the 90th percentile of the reference population. All other cases were considered normal vascular ageing (NVA). MEASUREMENTS: cf-PWV was measured by SphygmoCor® System; CAVI and ba-PWV were determined by Vasera 2000® device. Gut microbiome composition in faecal samples was determined by 16S rRNA Illumina sequencing. RESULTS: Mean age was 64.4 ± 6.9 in EVA group and 60.4 ± 7.6 years in NVA (p < .01). Women in EVA group were 41% and 53% in NVA. There were no differences in the overall composition of gut microbiota between the two groups when evaluating Firmicutes/Bacteriodetes ratio, alfa diversity (Shannon Index) and beta diversity (Bray-Curtis). Bilophila, Faecalibacterium sp.UBA1819 and Phocea, are increased in EVA group. While Cedecea, Lactococcus, Pseudomonas, Succiniclasticum and Dielma exist in lower abundance. In logistic regression analysis, Bilophila (OR: 1.71, 95% CI: 1.12-2.6, p = .013) remained significant. CONCLUSIONS: In the studied Spanish population, early vascular ageing is positively associated with gut microbiota abundance of the genus Bilophila. No relationship was found between phyla abundance and measures of diversity.
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Microbioma Gastrointestinal , Análise de Onda de Pulso , Humanos , Microbioma Gastrointestinal/fisiologia , Feminino , Masculino , Pessoa de Meia-Idade , Idoso , Espanha , Estudos Transversais , Envelhecimento/fisiologia , Índice Tornozelo-Braço , Rigidez Vascular/fisiologia , Fezes/microbiologia , Doenças Cardiovasculares/microbiologia , FirmicutesRESUMO
Background: Worldwide, chronic diseases are prevalent among the older adults, significantly affecting their health and healthcare system. The COVID-19 pandemic exacerbated these challenges, disrupting healthcare services. Our study assesses the impact on older individuals with chronic diseases who were not infected with COVID-19, analyzing comorbidities, medication use, mortality rates, and resource utilization using real data from Aragon, Spain. Methods: A retrospective observational study, conducted in Aragon, Spain, focused on individuals aged 75 and older with at least one chronic disease, who were not infected of COVID-19. The research used actual data collected during three distinct periods: the first covered the six months prior to the pandemic, the second the six months after the lockdown, and the third the period between six and twelve months. Key variables included socio-demographics, comorbidities, clinical parameters, medication use, and health services utilization. Results: We included 128.130 older adults. Mean age was 82.88 years, with 60.3% being women. The most common chronic diseases were hypertension (73.2%), dyslipidemia (52.5%), and dorsopathies (31.5%). More than 90% had more than 2 conditions. A notable decline in new chronic disease diagnoses was observed, particularly pronounced in the six to twelve months period after lockdown. Although statistically significant differences were observed in all clinical variables analyzed, they were considered clinically irrelevant. Furthermore, a decrease in healthcare services utilization and medication prescriptions was reported. Conclusion: Our study highlights a decrease in new chronic disease diagnoses, ongoing reductions in healthcare utilization, and medication prescriptions for older adults with pre-existing chronic conditions, unaffected by COVID-19.
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COVID-19 , Pandemias , Humanos , Feminino , Idoso , Idoso de 80 Anos ou mais , Masculino , COVID-19/epidemiologia , Doença Crônica , Prescrições de Medicamentos , Avaliação de Resultados em Cuidados de SaúdeRESUMO
BACKGROUND: International mobility of health workforce affects the performance of health systems and has major relevance in human resources for health policy and planning. To date, there has been little research exploring the reasons why general practitioners (GPs) migrate. This mixed methods study aimed to investigate the reasons why Spain-trained GPs migrate and develop GP retention and recruitment health policy recommendations relevant to Spanish primary care. METHODS: The study followed an explanatory sequential mixed methods study design combining surveys with semi-structured interviews and focus groups with GPs who qualified in Spain and were living overseas at the time of the study. The survey data examined the reasons why GPs left Spain and their intention to return and were analysed using quantitative methods. The transcripts from interviews and focus groups centred on GPs' insights to enhance retention and recruitment in Spain and were analysed thematically. RESULTS: The survey had 158 respondents with an estimated 25.4% response rate. Insufficient salary (75.3%), job insecurity and temporality (67.7%), excessive workload (67.7%), poor primary care governance (55.7%), lack of flexibility in the workplace (43.7%) and personal circumstances (43.7%) were the main reasons for leaving Spain. Almost half of the respondents (48.7%) would consider returning to Spanish general practice if their working conditions improved. Interviews and focus groups with respondents (n = 24) pointed towards the need to improve the quality of employment contracts, working conditions, opportunities for professional development, and governance in primary care for effective retention and recruitment. CONCLUSION: Efforts to improve GP retention and recruitment in Spain should focus on salary, job security, flexibility, protected workload, professional development, and governance. We draw ten GP retention and recruitment recommendations expected to inform urgent policy action to tackle existing and predicted GP shortages in Spanish primary care.
Assuntos
Medicina Geral , Clínicos Gerais , Humanos , Espanha , Emprego , Política de SaúdeRESUMO
BACKGROUND: Challenges of polypharmacy and the impact of coronavirus disease 2019 (COVID-19) pandemic in older patients require further investigation. This retrospective study analyzed the progression of polypharmacy and anticholinergic burden in older patients in a primary care setting before, during, and after the COVID-19 pandemic. METHODS: This 3-year cross-sectional study (2019, 2020, and 2021) comprised a dynamic cohort of individuals aged ≥75 years, who attended the Arrabal Primary Care Center in Zaragoza, Spain. Older patients with polypharmacy (≥5 medications) were identified according to their electronic health records. We collected demographic and clinical data, including medication prescriptions, diagnoses, and anticholinergic risks, and performed descriptive and statistical analyses. RESULTS: This study included a total of 1,928 patients with a mean age of 83.52±0.30 years. Over the 3-year study period, the mean number of medications prescribed increased, from 9.4 in 2019 to 10.4 in 2021. The prevalence of excessive polypharmacy (≥10 medications) increased from 39% in 2019 to 45% in 2021. The most commonly prescribed drugs were anilides, proton pump inhibitors, benzodiazepine derivatives, and platelet aggregation inhibitors. Women had a higher prevalence of illnesses and anticholinergic drug prescriptions than men. CONCLUSION: The results of this study highlighted an upward trend in polypharmacy and excessive polypharmacy among older patients in primary care settings. Future research should focus on optimizing medication management and deprescribing strategies and minimizing the adverse effects of polypharmacy in this population.
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Objetivos: conocer el grado de implementación de la Medicina Familiar y Comunitaria (MFyC) en el grado de Medicina de todas las universidades españolas.Métodos: estudio descriptivo transversal, llevado a cabo entre enero y marzo de 2023. Cuestionario ad hoc, cumplimentado por docentes de las 44 facultades de Medicina (año académico 2022-2023), sobre seis temáticas centradas en la asignatura de MFyC, las prácticas tuteladas, las rotaciones, metodologías docentes y evaluativas, y el profesorado. Resultados: participan 41 facultades (93,2%), 83% públicas y 17% privadas. La asignatura de MFyC está implantada en 34 facultades (82,9%), siendo obligatoria en 32 (94,1%), un 78% del total.La asignatura se denomina Medicina Familiar y Comunitaria solo en 14 facultades (34%) y cuenta con gran variabilidad en créditos ECTS: 3 créditos en 13 facultades (36%) y 6 créditos en 11 facultades (30%). Se imparte en quinto curso en 21 facultades (51%) y en sexto curso en 13 (32%). Hay prácticas tuteladas de MFyC en 28 facultades (68%) y créditos propios en 19 (46%). Mediana duración de 5 semanas. Gran variabilidad en las denominaciones. Coordinación por MFyC en 14 facultades (50%). Hay rotaciones en el centro de salud en 34 facultades (83%), siendo obligatorias en 29 (85%). No hay departamentos de Medicina Familiar, y solo hay unidades docentes universitarias en 4 facultades. Actualmente, hay 3 catedráticos y 13 profesores titulares. Conclusiones: se observa una progresión de la MFyC en la universidad en asignaturas, contenidos y profesorado, pero aún estamos lejos del nivel en el que se encuentran las universidades de otros países. Debilidades: gran heterogeneidad en denominación, contenidos, metodologías, carga docente y estructura. Fortalezas: implementación de metodologías docentes y evaluativas innovadoras.(AU)
Aims: to ascertain the degree of implementation of Family and Community Medicine (MFyC) on the undergraduate medicine degree course of Spanish universities.Methods: cross-sectional descriptive study, January-March 2023. Ad-hoc questionnaire, completed by lecturers of 44 medical schools (academic year 2022-2023). The questionnaire included six MFyC topics; that is, supervised family practice internships, shifts, teaching and evaluation methodologies and lecturers in medical schools.Results: a total of 41 faculties (93.2%) took part; 83% public and 17% private. MFyC course was implemented in 34 faculties (82.9%). The course was mandatory in 32 faculties (94.1%), 78% of the total.The course was named family and community medicine only in 14 medical schools (34%) with a major variability in ECTS credits (3 credits in 13 schools [36%] and 6 credits in 11 schools [30%]). It was taught in the 5th and 6th years in 21 (51%) and 13 (32%) faculties, respectively. There was supervised work experience in 28 faculties (68%), own credits in 19 (46%). Median duration was five weeks. There was a major variability in denomination. There was coordination by family practitioners in 14 faculties (50%).There were health centre internships in 34 faculties (83%), mandatory in 29 (85%).There are no family medicine departments and only university teaching units in four faculties. Currently, there are only three professors and 13 tenured lecturers.Conclusions: development of F&CM as a field was observed in terms of courses, content and teaching staff. However, this still falls well below international standards. Weaknesses are a major heterogeneity in denomination, content, methodologies, teaching load and structure and implementation of innovative teaching and evaluation methodologies was perceived as a strength.(AU)
Assuntos
Humanos , Medicina de Família e Comunidade/educação , Medicina/classificação , Educação Médica , Faculdades de Medicina , Estágio Clínico/métodos , Espanha , Estudos Transversais , Epidemiologia Descritiva , Inquéritos e Questionários , UniversidadesRESUMO
OBJECTIVE: To measure the impact of the community health programme "Education for health in adolescence" carried out in the Parquesol neighborhood, Valladolid (Spain), during the years 2015-2019. METHOD: Community-based quasi-experimental pre- and post-test analytical intervention trial with control group. A total of 407 adolescent surveys were collected. The CHIP-AE test validated for Spain was used. Pre- and post-test results were analyzed and compared with the control group. RESULTS: Improvements were found in the female intervention group compared to the control group in the variables resilience (3.68 vs. 3.41; p <0.01), health and safety at home (4.30 vs. 4.00; p <0.01), physical activities (3.16 vs. 2.60; p <0.01) and self-esteem (3.17 vs. 2.79; p <0.05). CONCLUSIONS: The community intervention carried out improves the health profile of adolescents. The baseline perception of health presents differences by gender, with higher scores in males. Post-intervention improvement is substantial in females in resilience, physical activities and health and safety at home. In addition, the worsening due to the passage of time described in previous studies is corrected in the variables self-esteem, satisfaction and well-being.
Assuntos
Aconselhamento , Educação em Saúde , Masculino , Humanos , Adolescente , Feminino , Autoimagem , Identidade de Gênero , Satisfação PessoalRESUMO
Objetivo: Medir el impacto del programa de intervención comunitaria «Educación para la salud en la adolescencia» llevado a cabo en el barrio de Parquesol, Valladolid, durante los años 2015-2019. Método: Ensayo comunitario de intervención cuasi experimental analítico pre- y postest con grupo control. Se recogieron 407 encuestas de adolescentes. Se utilizó el test CHIP-AE validado para España. Se analizaron los resultados pre- y postest y se compararon con el grupo control. Resultados: Se encontraron mejoras en el grupo de intervención femenino frente al grupo control en las variables resistencia (3,68 vs. 3,41; p < 0,01), salud y seguridad en el hogar (4,30 vs. 4,00; p < 0,01), actividades físicas (3,16 vs. 2,60; p < 0,01) y autoestima (3,17 vs. 2,79; p < 0,05). Conclusiones: La intervención comunitaria realizada mejora el perfil de salud de los/las adolescentes. La percepción basal de la salud presenta diferencias por sexo, con mayor puntuación en los hombres. La mejoría posintervención es sustancial en las mujeres en resistencia, actividades físicas y salud y seguridad en el hogar. Además, se corrige en la variable autoestima el empeoramiento debido al paso de los años descrito en estudios previos.(AU)
Objective: To measure the impact of the community health programme Education for health in adolescence carried out in the Parquesol neighborhood, Valladolid (Spain), during the years 2015-2019. Method: Community-based quasi-experimental pre- and post-test analytical intervention trial with control group. A total of 407 adolescent surveys were collected. The CHIP-AE test validated for Spain was used. Pre- and post-test results were analyzed and compared with the control group. Results: Improvements were found in the female intervention group compared to the control group in the variables resilience (3.68 vs. 3.41; p < 0.01), health and safety at home (4.30 vs. 4.00; p < 0.01), physical activities (3.16 vs. 2.60; p < 0.01) and self-esteem (3.17 vs. 2.79; p < 0.05). Conclusions: The community intervention carried out improves the health profile of adolescents. The baseline perception of health presents differences by gender, with higher scores in males. Post-intervention improvement is substantial in females in resilience, physical activities and health and safety at home. In addition, the worsening due to the passage of time described in previous studies is corrected in the variables self-esteem, satisfaction and well-being.(AU)
Assuntos
Humanos , Masculino , Feminino , Adolescente , Educação em Saúde , Planos e Programas de Saúde , Participação da Comunidade , Autoimagem , Comportamento do Adolescente , Medicina Comunitária , Saúde Pública , Saúde do Adolescente , Espanha , Inquéritos e Questionários , Promoção da SaúdeRESUMO
Introducción: Realizar de una forma adecuada una reanimación cardiopulmonar precisa unos conocimientos técnicos y unas mínimas condiciones físicas. Realizar esta reanimación un equipo de protección individual frente a riesgos biológicos nivel D colocado aumenta el sobresfuerzo al que se ven sometidos los reanimadores.El objetivo de este estudio es comprobar la existencia de un patrón de mala tolerancia fisiológica al uso de los equipos de protección nivel D, categoría 4-5-6B para la actuación en incidentes con riesgo biológico objetivado mediante la medición del índice de perfusión antes y después de una reanimación simulada.Material y métodos: Se ha realizado un estudio cuasiexperimental no controlado sobre 96 voluntarios elegidos mediante un muestreo aleatorio estratificado por sexo, nivel de formación y categoría profesional, estudiantes de Medicina y Enfermería y profesionales Médicos y Enfermeros. Se realizó una toma del índice de perfusión antes de realizar la reanimación y otra después de la reanimación simulada.Resultados: Un 15% de los voluntarios presentaron un índice de perfusión posterior más bajo al basal, lo que se traduce en una situación de vasoconstricción periférica después de la realización del ejercicio físico que supuso el caso clínico, cuando lo esperable era una vasodilatación para aumentar la perfusión.Conclusiones: Extrapolando estos datos, podemos concluir que, en la muestra de estudio que nos ocupa, los voluntarios que presentan menos índice de perfusión al finalizar que al comenzar no toleran bien el esfuerzo que supone el caso clínico
Introduction: Perform a cardiopulmonary resuscitation requires technical knowledge and minimal physical conditions. Perform this resuscitation a team of individual protection against biological risks level D placed increases the overexertion that encourage rescuers are subjected.The objective of this study is to prove the existence of a pattern of poor physiological tolerance to the use of personal protective equipment level D, category 4-5-6B for action in incidents with biological risk objectified by measuring the perfusion index before and after a simulated resuscitation.Material and methods: We have performed a quasiexperimental not controlled on 96 volunteers chosen through a random sampling, stratified by sex, level of education and professional category, medical and nursing students and professionals doctors and nurses.A decision of the perfusion index before performing the resuscitation and other simulated after resuscitation.Results: A 15% of the volunteers presented a perfusion index lower back to baseline, which translates into a situation of peripheral vasoconstriction after the completion of the physical exercise that involved the clinical case, when expected was a vasodilatation to Increase perfusion.Conclussion: Extrapolating these data, we can conclude that, in the sample for the study, the volunteers who have less perfusion index at the end of that at the beginning do not tolerate well the effort involved in the case
Assuntos
Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Relação Ventilação-Perfusão/fisiologia , Respiração Artificial/métodos , Reanimação Cardiopulmonar/efeitos adversos , Respiração Artificial/enfermagem , Estudos Controlados Antes e Depois , Voluntários Saudáveis/estatística & dados numéricos , Pessoal de Saúde/estatística & dados numéricos , Estudantes de Ciências da Saúde/estatística & dados numéricosRESUMO
INTRODUCTION: Certain professions, such as those related to emergency services, have usually been performed by men, progressively incorporating women into these professions. The main objective of our study was to determine, according to gender, how the use of level D biohazard personal protection equipment (PPE) affects emergency professionals during the performance of resuscitation. MATERIALS AND METHODS: An uncontrolled quasi-experimental study was performed on 96 volunteers selected by means of random sampling stratified by gender. Baseline and final vital signs of the assessment activity were analyzed. This activity involves volunteers performing a simulated resuscitation in a controlled environment whilst wearing personal protective suits in a biohazard situation. RESULTS: Analyzing the physiological tolerance pattern parameter by parameter, and according to gender, through a univariate model, we can observe that there is no interaction between tolerance and gender; that is, having good or bad tolerance does not depend on gender. Conclusion. This specialized skilled work can be performed by any properly trained professional.
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Objetivo. Determinar cómo afecta el uso de los equipos de protección individual (EPI) nivel D a los trabajadores de la salud cuando realizan una reanimación. Métodos. Estudio cuasiexperimental no controlado sobre 96 voluntarios elegidos mediante un muestreo aleatorio estratificado por sexo, nivel de formación y categoría profesional, de una muestra de oportunidad de 164 voluntarios, 40 hombres (41,66%) y 56 mujeres (58,33%), con una edad media de 31 (DE 11) años, estudiantes de medicina y enfermería y profesionales médicos y enfermeros. Mediante el uso de un protocolo Conconi con cicloergometría se obtuvo la frecuencia cardiaca (FC) del umbral anaeróbico de los voluntarios, y después se comparó con la FC máxima de los voluntarios durante la realización de una reanimación con el EPI colocado. Resultados. Durante los minutos correspondientes a la realización del masaje cardiaco externo durante la reanimación en el caso clínico, un 46,9% de los voluntarios sobrepasan la FC máxima recomendable obtenida mediante la ciclo ergometría. Conclusiones. Nuestro estudio encontró que la realización de una reanimación con un EPI nivel D supone un sobresfuerzo físico muy intenso. Es necesario tener contemplado en los protocolos estas situaciones especiales e implementar un entrenamiento específico para aquellos reanimadores que deban trabajar con este tipo de pacientes (AU)
Objective. Our aim was to determine the usefulness of level D personal protective equipment (PPE) in safeguarding health care staff who perform cardiopulmonary resuscitation (CPR). Methods. Quasi-experimental, uncontrolled trial in 96 volunteers chosen randomly and stratified by sex, level of training, and professional category. The subjects were selected from a convenience sample of 164 nurses, physicians, and students of nursing and medicine (40 men [41.66%] and 56 women [58.33%]). The mean (SD) age was 31 (11) years. The Conconi test was used to determine heart rate (HR) at the anaerobic threshold on a cycle ergometer. That HR was then compared to each volunteer's maximum HR during performance of CPR while wearing PPE. Results. While the volunteers were performing CPR, 46.9% of them surpassed their maximum recommendable HR recorded during the cycle ergometer test. Conclusions. We found that performing CPR while wearing level D PPE requires intense physical effort. Special situations should be taken into consideration when developing protocols for situations that require staff to wear PPE. Staff who must perform CPR under these conditions should be given specific training (AU)
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Equipamento de Proteção Individual , Contenção de Riscos Biológicos/métodos , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar , Contenção de Riscos Biológicos/prevenção & controle , Sala de Recuperação/organização & administração , Serviços Médicos de Emergência/métodos , Voluntários Saudáveis , Estresse FisiológicoRESUMO
OBJECTIVES: Our aim was to determine the usefulness of level D personal protective equipment (PPE) in safeguarding health care staff who perform cardiopulmonary resuscitation (CPR). MATERIAL AND METHODS: Quasi-experimental, uncontrolled trial in 96 volunteers chosen randomly and stratified by sex, level of training, and professional category. The subjects were selected from a convenience sample of 164 nurses, physicians, and students of nursing and medicine (40 men [41.66%] and 56 women [58.33%]). The mean (SD) age was 31 (11) years. The Conconi test was used to determine heart rate (HR) at the anaerobic threshold on a cycle ergometer. That HR was then compared to each volunteer's maximum HR during performance of CPR while wearing PPE. RESULTS: While the volunteers were performing CPR, 46.9% of them surpassed their maximum recommendable HR recorded during the cycle ergometer test. CONCLUSION: We found that performing CPR while wearing level D PPE requires intense physical effort. Special situations should be taken into consideration when developing protocols for situations that require staff to wear PPE. Staff who must perform CPR under these conditions should be given specific training.
OBJETIVO: Determinar cómo afecta el uso de los equipos de protección individual (EPI) nivel D a los trabajadores de la salud cuando realizan una reanimación. METODO: Estudio cuasiexperimental no controlado sobre 96 voluntarios elegidos mediante un muestreo aleatorio estratificado por sexo, nivel de formación y categoría profesional, de una muestra de oportunidad de 164 voluntarios, 40 hombres (41,66%) y 56 mujeres (58,33%), con una edad media de 31 (DE 11) años, estudiantes de medicina y enfermería y profesionales médicos y enfermeros. Mediante el uso de un protocolo Conconi con cicloergometría se obtuvo la frecuencia cardiaca (FC) del umbral anaeróbico de los voluntarios, y después se comparó con la FC máxima de los voluntarios durante la realización de una reanimación con el EPI colocado. RESULTADOS: Durante los minutos correspondientes a la realización del masaje cardiaco externo durante la reanimación en el caso clínico, un 46,9% de los voluntarios sobrepasan la FC máxima recomendable obtenida mediante la ciclo ergometría. CONCLUSIONES: Nuestro estudio encontró que la realización de una reanimación con un EPI nivel D supone un sobresfuerzo físico muy intenso. Es necesario tener contemplado en los protocolos estas situaciones especiales e implementar un entrenamiento específico para aquellos reanimadores que deban trabajar con este tipo de pacientes.
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Reanimação Cardiopulmonar , Substâncias Perigosas , Pessoal de Saúde , Equipamento de Proteção Individual , Adulto , Reanimação Cardiopulmonar/educação , Teste de Esforço , Feminino , Frequência Cardíaca , Humanos , Masculino , Enfermeiras e Enfermeiros , Equipamento de Proteção Individual/efeitos adversos , Esforço Físico , Médicos , Estudantes de Medicina , Estudantes de Enfermagem , Adulto JovemRESUMO
No disponible
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Humanos , Medicina de Família e Comunidade/legislação & jurisprudência , Ocupações em Saúde/legislação & jurisprudência , Ocupações em Saúde/normas , Atenção Primária à Saúde/organização & administração , Medicina de Família e Comunidade/educação , Médicos de Família/legislação & jurisprudência , Médicos de Família/organização & administração , Internato e Residência/organização & administração , Internato e Residência/normasRESUMO
No disponible
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Humanos , Fumar/epidemiologia , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Isquemia Miocárdica/epidemiologia , Indicadores de Morbimortalidade , Espanha/epidemiologia , Distribuição por SexoAssuntos
Isquemia Miocárdica/mortalidade , Doença Pulmonar Obstrutiva Crônica/mortalidade , Tabagismo/mortalidade , Feminino , Humanos , Masculino , Isquemia Miocárdica/etiologia , Doença Pulmonar Obstrutiva Crônica/etiologia , Espanha/epidemiologia , Fatores de Tempo , Tabagismo/complicações , Tabagismo/prevenção & controleRESUMO
No disponible
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Humanos , Necessidades e Demandas de Serviços de Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde/normas , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/normas , Atenção Primária à Saúde , Enfermeiros Administradores/organização & administração , Enfermeiros Administradores/normas , Atenção Primária à Saúde , Administração de Serviços de Saúde/normas , Administração de Serviços de Saúde/tendências , Enfermeiros Administradores/tendênciasRESUMO
No disponible