The experiences of older individuals providing care to older dependents: A phenomenological study in Spain.

OBJECTIVE: Non-professional care provided in domestic settings by a family member or someone from the close environment and without a connection to a professional care service, is increasingly assumed by older people, mainly the spouses of those requiring care. The aim of this study was to describe the experience of older people providing care at home to older dependents. METHODS: A qualitative study was carried out to describe and explore the experience of older people, caregivers of dependent older people in the home. RESULTS: Four themes emerged as a result of the analysis: interpersonal relationships established in the caregivers' immediate environment; the need and request for public and private resources; consequences of providing care during old age; and adaptation to the circumstance of being a caregiver during old age. Older people who provide home-based care, experience their situation as stressful, feel that it limits their daily life, deprives them of their freedom, and affects their interpersonal relationships and social activities. DISCUSSION: Older caregivers learn quickly and can manage the skills issues. The volume of work is their challenge. Interpersonal relationships are altered depending on the length of time spent together and the demand for care. Public services and benefits are not adapted to the demands of caregivers or dependent persons.

Evaluation of new biomarkers of stress in saliva of sheep.

Some routine handling procedures can produce stress in farm animals, and an adequate control of these stressors is important to avoid the negative effects on animal health and production. The measurement of biomarkers in saliva can be a suitable tool for the evaluation and control of stress. In this report, lipase, butyrylcholinesterase (BChE), total esterase (TEA) and adenosine deaminase (ADA) activities in the saliva of sheep were evaluated as biomarkers of stress. For this purpose, they were measured after inducing stress by facing a dog (experiment 1) and shearing (experiment 2), and comparing them to other stress salivary biomarkers such as α-amylase (sAA) and cortisol, as well as heart rate (HR). Each analyte was measured at the basal time, and during and just after the end of the stressful stimulus, and at various times for the first hour after the period of stress induction. Values were compared with those obtained from a control group. Lipase was the only analyte that showed significant changes between the stress and the control group in both experiments. Although TEA and ADA increased after stress, no significant differences were seen compared with the control group. Lipase was correlated highly with sAA and HR, in experiment 1; and correlated moderately with cortisol and HR in experiment 2. Lipase showed the greatest percentage increase after the stressful stimuli and less overlap with the control group in the two experiments. From the results of this study it can be concluded that lipase, TEA, BChE and ADA are enzymes present in the saliva of sheep and that they can be measured by using simple and fast colorimetric methods. Further studies should be undertaken with regard to the possible application of lipase as a biomarker of stress in sheep.

Síndrome piramidal y variaciones anatómicas como causa de dolor ciático insidioso / Pyrimidal syndrome and anatomical variations as a cause of insidious sciatic pain

Mujer de 42 años, que presentó durante 6 años clínica insidiosa de dolor e impotencia funcional de miembro inferior izquierdo con pruebas diagnósticas normales llegando a un diagnóstico de exclusión de origen funcional. Fue sometida a tratamientos y técnicas conservadores sin mejoría por lo que se decidió realizar cirugía exploratoria donde se observó una compresión del nervio ciático por una variación anatómica del músculo piriforme. Tras resecar parte del músculo piramidal y liberarse la rama del nervio ciático afectada, se constató mejoría del cuadro clínico quedando la paciente asintomática (AU)

The case is presented of a 42 year old woman who had been suffering a loss of strength in her left leg for six years. After an extensive diagnostic study, the pain was classified as of functional origin by a diagnosis of exclusion. Since then, the patient has tried all kind of drug treatments and conservative techniques without improvement. After an exhaustive study with inconclusive results, the case was discussed with the Orthopaedics Department, who performed an exploratory surgery, in which compression of the sciatic nerve due to an anatomical variation of the piriformis muscle was observed. Part of the muscle was resected during surgery and the sciatic nerve was freed, after which the patient experienced a great improvement (AU)

[Pyrimidal syndrome and anatomical variations as a cause of insidious sciatic pain]. / Síndrome piramidal y variaciones anatómicas como causa de dolor ciático insidioso.

The case is presented of a 42 year old woman who had been suffering a loss of strength in her left leg for six years. After an extensive diagnostic study, the pain was classified as of functional origin by a diagnosis of exclusion. Since then, the patient has tried all kind of drug treatments and conservative techniques without improvement. After an exhaustive study with inconclusive results, the case was discussed with the Orthopaedics Department, who performed an exploratory surgery, in which compression of the sciatic nerve due to an anatomical variation of the piriformis muscle was observed. Part of the muscle was resected during surgery and the sciatic nerve was freed, after which the patient experienced a great improvement.

High hydrostatic pressure treatment provides persimmon good characteristics to formulate milk-based beverages with enhanced functionality.

High hydrostatic pressure (HHP) applied during food processing can improve the retention of food quality attributes and nutritional values in comparison with pasteurization. Persimmon is a good source of bioactive compounds but it is a seasonal fruit that cannot be consumed throughout the year. The aim of this work was to compare the HHP and pasteurization treatments to formulate milk-based beverages containing this carotenoid rich ingredient and to evaluate their performance in these beverages. The carotenoid and tannin contents of persimmon were determined and the microstructure and rheology of the new milk-based persimmon beverages were examined. The results showed that HHP treatment favoured the release of carotenoids from the fruit matrix and precipitation of the tannins. The milk-based beverages prepared with the high-pressure persimmon presented the best rheological properties because unlike the untreated and pasteurized persimmon milk-based beverages, they did not form a gel-like structure or separate out.

Impact of high hydrostatic pressure and pasteurization on the structure and the extractability of bioactive compounds of persimmon "Rojo Brillante".

Rojo Brillante is an astringent oriental persimmon variety with high levels of bioactive compounds such as soluble tannins, carotenoids, phenolic acids, and dietary fiber. The purpose of this study was to investigate the effects of high hydrostatic pressure (HHP) and pasteurization on the structure of the fruit and on the extractability of certain bioactive compounds. The microstructure was studied using light microscopy, transmission electron microscopy, and low temperature scanning electron microscopy, and certain physicochemical properties (carotenoid and total soluble tannin content, antioxidant activity, fiber content, color, and texture properties) were measured. The structural changes induced by HHP caused a rise in solute circulation in the tissues that could be responsible for the increased carotenoid level and the unchanged antioxidant activity in comparison with the untreated persimmon. In contrast, the changes that took place during pasteurization lowered the tannin content and antioxidant activity. Consequently, HHP treatment could improve the extraction of potentially bioactive compoundsxsts from persimmons. A high nutritional value ingredient to be used when formulating new functional foods could be obtained using HHP.

Identificación de factores predictores de técnica epidural dificultosa en la paciente obstétrica / No disponible

Introducción: Los intentos repetidos de punción son factores de riesgo para la aparición de complicaciones neurológicas secundarias a la práctica de la analgesia espinal y aumentan la ansiedad del paciente. El objetivo de este estudio es determinar qué factores son mejores predictores de la colocación dificultosa del catéter epidural en la paciente obstétrica. Material y método: Estudio observacional y prospectivo en 120 gestantes a término que solicitan la analgesia epidural para el trabajo de parto. Se recogen variables demográficas y antecedentes de anestesia espinal previa no exitosa o considerada dificultosa por la paciente. Se identifican variables anatómicas y se clasifica la calidad de los puntos de referencia anatómicos según los criterios publicados por Chien en cuatro grados. Las condiciones de la técnica y la experiencia del anestesiólogo son similares en todos casos. Consideramos punción dificultosa si se necesita más de una punción en la piel o una punción pero más de un cambio de dirección de aguja en el espacio interespinoso. Se recoge el éxito obtenido y las complicaciones de la técnica. Resultados: Fueron calificadas de punción difícil según los criterios del estudio en el 36,67 % de los casos. En la mayoría de los casos la técnica fue efectiva obteniendo una adecuada analgesia. La incidencia de repunción epidural fue de 5 %. En las pacientes clasificadas en el grado 4, la tasa de punción epidural considerada dificultosa supuso un 90 %, necesitando en el 80 % de esos casos 3 o más intentos. En las pacientes con antecedentes personales de técnica neuroaxial dificultosa se encontró dificultad de punción epidural en un 28,57 % de los casos. El hábito corporal no tuvo efecto significativo sobre la tasa de éxito con el primer intento. Discusión: Nuestro estudio representa una buena estimación de la dificultad técnica de un bloqueo neuroaxial. Seria difícil saber si los datos reflejados serían extrapolables a la realización de la técnica en decúbito lateral, donde los puntos de referencia anatómicos son más difíciles de identificar. Conclusiones: Nuestra recogida concluye que el método más fiable para determinar de antemano la posibilidad de una dificultad técnica de colocación del catéter epidural lumbar es un examen de la espalda de la paciente para identificar la calidad de los puntos de referencia anatómicos e identificar la deformidad obvia de la columna vertebral (AU)

Introduction: Repeated attempts punctureare risk factors for the appearance of neurologic complications caused by the practice of spinal analgesia and increase patient anxiety. The purpose of this study is to determine which factor sare better predictors of difficult epidural catheter placement in the obstetric patient. Material and methods: Prospective observational study in 120 pregnant women at term who request edepidural analgesia during labor. Demographic variables and history of difficult or unsuccessful spinal anesthesia were collected. Anatomical variables were identified and the quality of anatomical landmarks was classified according to criteria published by Chien in four grades. The conditions of the technique and the experience of anesthesiologists were similar in all cases. It was considered as difficult puncture that in which was made more than one attempt on skin or more than one change of direction with the epidural needle in interspinous space.We collected the successand complications of the technique. Results: 36.67 % of cases were classified as difficult punctures according to the criteria of the study. In most cases the technique was effective obtaining asuccessful analgesia. The incidence of repeat epidural puncture was 5 %. In patients classified in grade 4, the percentage of difficult epidural puncture was 90 %, requiring in 80 % of the cases 3 or more attempts. In patients with a history of difficult neuraxial technique in 28.57 % of the cases was found difficulty in epidural puncture. Body habitus had no significant effect on the rate success in first attempt. Discussion: Our study represents a good estimationof a difficult neuraxial blockade. It would bedifficult to know if there flected datawould be applicable to the lateral decubitus technique where anatomical landmarksare more difficult to identify. Conclusions: Our study concludes thatt he most reliable method to predict the possibility of a technical difficulty in the placement of lumbar epidural catheter, is the examination of the back of the patient to identify the quality of anatomical landmarks and identify obvious deformities of the spine (AU)

Programa de Salud para niños y adolescentes con síndrome de Down / Health Program for children and adolescents with Down’s syndrome

Los problemas específicos de salud que presentan los niños con síndrome de Down deben ser objeto de atención por los pediatras. Para integrar estos cuidados con los propios de la edad, diversas organizaciones pediátricas han elaborado programas de salud para personas con síndrome de Down. En ellos se puntualiza sobre las necesidades específicas de los pacientes con trisomía 21, añadiéndolas a las propias de las diversas edades. Los programas de salud suponen una ayuda importante para la atención pediátrica a este grupo poblacional (AU)

Special attention should be given by the pediatricians to the specific health problems that children with Down’s Syndrome have. In order to integrate these cares into those cares characteristic for their age, different pediatric organizations have elaborated health programs for persons with Down’s Syndrome. In these, the specific needs of the patients with trisomy 21 are highlighted, adding these to those characteristic for the different ages. The health programs suppose an important aid for the pediatric care to this population group (AU)

Spinal arachnoid cyst as an infrequent cause of spinal cord compression.

Spinal arachnoid cysts are rare lesions that may produce symptoms by compressing the spinal cord or nerve roots. MRI is essential for diagnosing this entity. We retrospectively reviewed the medical charts, radiological examinations, and follow-up data of four adults with spinal arachnoid cysts diagnosed in our center over a two-year period (2007-2009). All cysts were located in the thoracic spine. Three were dorsolateral to the spinal cord and one was ventral. Most had multiple septa but one had a single septum. Cyst size varied greatly; one cyst extended through eight vertebral bodies. One patient treated expectantly died of cardiovascular problems one year after the cyst was diagnosed. The other three patients underwent laminectomy and cyst fenestration; two had clinical and imaging signs of relapse after surgery. One of the patients with a relapsed cyst worsened clinically, developing syringomyelia and requiring reintervention with shunting to the subarachnoid space. The outcome of the operation was good in the case of the single septum. Spinal arachnoid cyst is uncommon. Its diagnosis is complex because the symptoms are unspecific and the imaging findings are subtle. Spinal arachnoid cyst should be included in the differential diagnosis of chronic paraparesis. Imaging plays an essential role in the diagnosis, follow-up and management of spinal arachnoid cysts.

Wallerian degeneration in the corticospinal tract evaluated by diffusion tensor imaging correlates with motor deficit 30 days after middle cerebral artery ischemic stroke.

BACKGROUND AND PURPOSE: The quantification and clinical significance of WD in CSTs following supratentorial stroke are not well understood. We evaluated the anisotropy by using DTI and signal-intensity changes on conventional MR imaging in the CST to determine whether these findings are correlated with limb motor deficit in patients with MCA ischemic stroke. MATERIALS AND METHODS: We studied 60 patients within 12 hours of stroke onset. At admission, day 3, and day 30 of evolution, patients underwent multimodal MR imaging, including DTI sequences. We assessed the severity of limb weakness by using the motor subindex scores (5a, 5b, 6a, 6b) of the m-NIHSS and established 3 groups: I (m-NIHSS scores of 0), II (m-NIHSS, 1-4), and III (m-NIHSS, 5-8). FA values and rFAs were measured on the affected and the unaffected CSTs in the pons. RESULTS: FA values for the CST were significantly lower on the affected side compared with the unaffected side only at day 30 (P < .001), and the rFA was significantly correlated with the motor deficit at day 30 (P < .001; r = -0.793). The sensitivity, specificity, and positive and negative predictive values for motor deficit by rFA < 0.925 were 95.2%, 94.9%, 90.9%, and 97.4%, respectively. CONCLUSIONS: WD in the CST revealed by DTI correlates with motor deficit 30 days after MCA ischemic stroke. This study highlights the utility of imaging follow-up at 30 days and the potential of DTI as a surrogate marker in clinical trials.

Resultados de un programa de prevención de exposiciones accidentales a fluidos biológicos en personal sanitario basado en la mejora del grado de cumplimiento de las precauciones estándar / Results of a program of prevention of accidental exposure to biological fluids in healthcare workers based on the improvement of the compliance of Standard Precautions

Objetivo: Evaluar un programa de prevención de exposiciones accidentales a fluidos biológicos basado en la mejora del grado de cumplimiento (GC) de las Precauciones Estándar (PE). Material y métodos: Intervenciones: primera (realización sesiones de actualización y reparto de trípticos informativos), y segunda (reparto de trípticos). Indicadores: Nivel de Conocimientos (NC), medido con un cuestionario de cinco preguntas, se consideró inadecuado cuando se fallaban tres o más preguntas; GC de PE medido en cuatro áreas (Higiene Manos -HM-, utilización de guantes -UG-, utilización adecuada métodos barrera -UAMB- y manejo adecuado objetos cortantes -MAOC-; Incidencia de inoculaciones y de exposiciones de mucosas a fluidos corporales. Resultados. La frecuencia de cuestionarios inadecuados paso del 54,6% al 23,3%(<0.001). La frecuencia HM pasó del 53,5% al 58,2%(<0,01), la UG del 78,7% al 84,6%(0,058), el UAMB del 53,8% al 55.5%(N.S.) y el MAOC del 52,9% al 54,0%(N.S.). La Incidencia inoculaciones paso del 5,53% al 4,98%(N.S.) y las exposiciones de mucosas del 0,95% al 0,81%(N.S.). Conclusiones: El programa ha mejorado los conocimientos del personal sobre PE, y el GC de PE y ha disminuido la incidencia exposiciones accidentales a fluidos biológicos aunque no de manera estadísticamente significativa (AU)

Introduction: The aim is to evaluate a program of prevention of accidental exposure to biological fluids based on the improvement of the compliance to Standard Precautions (SP). Methods: Interventions: first (update sessions and distributing pamphlets), and second (distributing pamphlets). Indicators: Level of knowledge (LK), measured with a 5-item questionnaire, with three or more incorrect answers considered inadequate; Compliance to SP measured in four areas (Hand Hygiene Hands -HH-, utilization of gloves - GU-, suitable utilization methods barrier - SUMB - and suitable managing cutting objects - SMCO-; Incident of percutaneus injuries and of exposure of mucous to corporal fluids. Results: The frequency of inadequate questionnaires I happen from 54,6 % to 23,3 % (<0.001). The frequency HH happened from 53,5 % to 58,2 % (<0,01), the GU of 78,7 % to 84,6 % (0,058), the SUMB of 53,8 % to 55.5 % (N.S.) and the SMCO of 52,9 % to 54,0 % (N.S.). The Incident percutaneus injuries from 5,53 % to 4,98 % (N.S.) and the exposure of mucous from 0,95 % to 0,81 % (N.S.). Conclusion: The program has improved in the knowledge of the personnel on SP, and has improved SP compliance and the Incident has diminished accidental exhibitions to biological fluids though not in a statistically significant way (AU)

Improving the quality of fresh-cut apples, pears, and melons using natural additives.

Improving the quality of different fresh-cut fruits by adding natural substances was studied. "Fuji" apples, "Flor de Invierno" pears, and "Piel de Sapo" melons were treated with calcium lactate, N-acetyl-L-cysteine, glutathione, and malic acid and stored for 4 wk at 4 degrees C. Instrumental texture (penetration), microstructure (light microscopy), acidity, soluble solids, color, pectinmethylesterase activity, and microflora were studied. The results showed that the combined treatment reinforced the cell walls strengthening the structure and texture of these fruits and maintained the L* and a* values throughout 4 wk of storage at 4 degrees C. The combination of additives provided low microbial counts in apples until the 4th week and in melons until the 2nd week. So, this combined treatment could be used to extend the shelf life of some fresh-cut fruits while preserving their quality.

Variability in the behavior of kids born of primiparous goats during the first hour after parturition: effect of the type of parturition, sex, duration of birth, and maternal behavior.

The aim of the study was to determine the effect of the type of birth, the sex of the kids, the duration of the birth (categorized as short, medium, or long), and the level of maternal care (categorized as low, medium, or high) on the behavioral variables of kids during the first hour after birth. The parturitions of 78 primiparous goats of Murciano-Granadina breed (46 single-birth and 32 twin-birth) along with the behavior of the kids (44 males and 66 females) during the first hour of life were studied. Birth weight and duration of parturition were greater in single-birth kids (2.94 kg and 60.5 min, respectively) than in twin-birth kids (2.27 kg and 43.2 min, respectively). Birth weight and duration of parturition was greater in males (2.74 kg and 54.61 min) than in females (2.43 kg and 47.70 min). All the kids attempted to stand during the first hour of life, but only 83% attempted to suckle with 65% succeeding. Single-birth kids attempted to stand earlier than twin-birth kids (7.05 vs. 9.08 min), although they achieved this later (16.87 vs. 13.21 min). Compared with twin-birth kids, single-birth kids attempted to suckle later (22.45 vs. 34.76 min, respectively) and achieved it later (25.69 vs. 37.32 min). In the single-birth kids the duration of the first suckling was shorter (16.11 vs. 22.26 s), although total suckling time was greater (5.86 min) than in the twin-birth kids. Males tried to stand sooner than females (7.41 vs. 8.78 min), but took longer (16.12 vs. 13.81 min). The sex factor had no significant effect on suckling-related variables. Compared with medium- and long-duration-birth kids, short-duration-birth kids attempted to suckle earlier, (29.34, 34.23, and 12.82 min, respectively), achieved suckling earlier (31.75, 37.00, and 16.70 min, respectively), and suckled longer at first attempt (0.32, 0.17, and 0.45 min, respectively). Total suckling time was longer in long-duration-birth kids than in medium- and short-duration birth (9.07, 2.63, and 3.86 min, respectively). These results suggest that heavier kids suffer more during birth and are slower to achieve suckling; however, they appear to recover quickly because the total suckling time observed during the first hour was greater.

Paroxysmal dystonia and pathological laughter as a first manifestation of multiple sclerosis.

Paroxysmal dystonia is an uncommon but well-established feature of multiple sclerosis (MS). Attacks can occur in established MS and may even occasionally be the initial symptom of this disorder. Pathological laughter is usually seen as a pseudobulbar palsy in some diffuse neurological diseases, but cases have been described, mostly in ischaemic attacks or tumours, where it is presented as bursts of laughter of variable duration. The pathogenesis of neither of the two phenomena has been fully established but both have been reported as being positive phenomena resulting from ectopic activation with ephaptic spread. We describe the first reported case of a paroxysmal hemidystonia together with bursts of pathological laughter as the first manifestation of MS.

Evaluación de un programa de actualización de las recomendaciones sobre la higiene de manos / Evaluation of a program for updating recommendations about hand hygiene

Introducción. La higiene de manos (HM) es la medida más importante para prevenir las infecciones nosocomiales. El objetivo es evaluar el programa de actualización de las recomendaciones sobre HM implantado. Material y métodos. Intervenciones: marzo-octubre/2005 se realizaron sesiones de actualización sobre cuándo y cómo realizar la HM y mayo/2006 se repartió un tríptico explicativo a todos los trabajadores informando del grado de cumplimiento de las recomendaciones. Indicadores: nivel conocimientos (NC) medido con un cuestionario de cinco preguntas que se pasaba antes y después de las sesiones y se consideró respuesta inadecuada cuando se fallaban tres o más preguntas; el consumo soluciones alcohólicas (CSA) en ml/estancia agrupado en semestres desde 2004-2006; el grado cumplimiento de recomendaciones (GCR) sobre la HM medida por observación directa en dos momentos (diciembre/2005-febrero/2006 y octubre-noviembre/ 2006) y la prevalencia de infecciones nosocomiales (PI) y de pacientes con infección nosocomial (PPI) a partir estudios EPINE 2004-2005-2006. Resultados. La frecuencia de respuestas inadecuadas para evaluar NC pasó de un 57,5% antes a 18,9% después (p<0,001). El CSA para HM pasó de 3 ml/estancia en 2º semestre/2004 a 17 ml/estancia en 2º semestre/2006 (p<0,001). El GCR ha pasado del 31,0% al 55,6% (p<0,001). La PI y PPI han pasado del 11,4% y el 9,6% respectivamente en el 2004 al 9,4% y 8,9% en 2006 (N.S.). Conclusión. El programa está consiguiendo de manera progresiva sus objetivos ya que los tres indicadores de proceso (NC, CSA, GC) han mejorado de manera estadísticamente significativa, y los de resultado (PI y PPI) han mejorado aunque sin significación estadística

Background. Hand Hygiene (HH) is the most important measure in the prevention of nosocomial infections. The objective was to evaluate the program for updating recommendations on HH that had been introduced. Methods. Interventions: between March-October/2005 realisation of updating sessions about when and how to realize HH and May/2006 distribution of an explicative three-part document to all healthcare workers reporting on compliance with the recommendations. Indicators: level of knowledge (LK) measured with a questionnaire of five questions that was given to those attending before and after sessions, responses were considered inadequate when three or more questions were not answered; consumption of alcoholic solutions (CAS) on ml/stay grouped into semesters from 2004-2006; compliance (CO) with recommendations on HH was measured by direct observation at two times (December/2005-February/2006 and October- November/2006); and infections prevalence (IP) and patients with infection (IPP) for EPINE studies 2004-2005-2006. Results. The frequency of inadequate answers for evaluating LK has fallen from 57,5% before to 18,9% afterwards (p <0.001). The CAS for HH has passed from 3 ml/stay in 2nd semester/2004 to 17 ml/stay 2nd semester/2006 (p <0.001). The CO with HH has risen from 31,0% to 55,6% (p <0.001). The IP and IPP have risen respectively from 11,4% and 9,6% in 2004 to 9,4% and 8,9% in 2006 (N.S.). Conclusion. The program is progressively achieving its objectives as the three process indicators (LK, CAS, CO) have improved in a statistically significant way, and the indicators of results (IP and IPP) have improved but without achieving statistical significance

[Evaluation of a program for updating recommendations about hand hygiene]. / Evaluación de un programa de actualización de las recomendaciones sobre la higiene de manos.

BACKGROUND: Hand Hygiene (HH) is the most important measure in the prevention of nosocomial infections. The objective was to evaluate the program for updating recommendations on HH that had been introduced. INTERVENTIONS: between March-October/2005 realisation of updating sessions about when and how to realize HH and May/2006 distribution of an explicative three-part document to all healthcare workers reporting on compliance with the recommendations. Indicators: level of knowledge (LK) measured with a questionnaire of five questions that was given to those attending before and after sessions, responses were considered inadequate when three or more questions were not answered; consumption of alcoholic solutions (CAS) on ml/stay grouped into semesters from 2004-2006; compliance (CO) with recommendations on HH was measured by direct observation at two times (December/2005-February/2006 and October-November/2006); and infections prevalence (IP) and patients with infection (IPP) for EPINE studies 2004-2005-2006. RESULTS: The frequency of inadequate answers for evaluating LK has fallen from 57.5% before to 18.9% afterwards (p <0.001). The CAS for HH has passed from 3 ml/stay in 2nd semester/2004 to 17 ml/stay 2nd semester/2006 (p <0.001). The CO with HH has risen from 31.0% to 55.6% (p <0.001). The IP and IPP have risen respectively from 11.4% and 9.6% in 2004 to 9.4% and 8.9% in 2006 (N.S.). CONCLUSION: The program is progressively achieving its objectives as the three process indicators (LK, CAS, CO) have improved in a statistically significant way, and the indicators of results (IP and IPP) have improved but without achieving statistical significance.