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Background: L-2-hydroxyglutaric aciduria (L2HGA) is a rare inherited autosomal recessive neurometabolic disorder caused by pathogenic variants in the L2HGDH gene which encodes mitochondrial 2-hydroxyglutarate dehydrogenase. Here, we report a case of L2HGA in a Mexican-Mayan patient with a homozygous mutation at L2HGDH gene and clinical response to vitamin supplements and levocarnitine. Case report: A 17-year-old, right-handed female patient with long-term history of seizures, developmental delay and ataxia was referred to a movement disorders specialist for the evaluation of tremor. Her brain MRI showed typical findings of L2HGA. The diagnosis was corroborated with elevated levels of 2-hydroxyglutaric acid in urine and genetic test which revealed a homozygous genetic known variant c.569C>T in exon 5 of L2HGDH gene. She was treated with levocarnitine and vitamin supplements, showing improvement in tremor and gait. Discussion: To our knowledge this is the first report of a Mexican patient with L2HGA. This case adds information about a rare condition in a different ethnic group and supports the findings of other authors which encountered symptomatic improvement with the use of flavin adenine dinucleotide (and its precursor riboflavin), and levocarnitine. Highlights: We report the first case of Mexican-Mayan patient with L2HGA showing a missense homozygous mutation in L2HGDH gene, and improvement of symptoms with vitamin supplements and levocarnitine.

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There is a paucity of genetic characterization in people with Parkinson's disease (PD) of Latino and Afro-Caribbean descent. Screening LRRK2 and GBA variants in 32 New Yorkers of Puerto Rican ethnicity with PD and in 119 non-Hispanic-non-Jewish European PD cases revealed that Puerto Rican participants were more likely to harbor the LRRK2-p.G2019S variant (15.6% vs. 4.2%, respectively). Additionally, whole exome sequencing of twelve Puerto Rican and Dominican PD participants was performed as an exploratory study.

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Resumen Objetivo: Determinar la latencia diagnóstica en la enfermedad de Parkinson (EP), así como su relación con variables clínicas y demográficas. Determinar la percepción de síntomas no motores: disfunción olfatoria, trastorno conductual del sueño MOR, depresión y estreñimiento, previos al diagnóstico de EP. Materiales y métodos: Estudio transversal realizado en Yucatán, México en sujetos con EP. Se analizó la asociación entre la latencia diagnóstica con variables clínicas y demográficas usando las pruebas estadísticas no paramétricas: U de Mann Whitney y Kruskal-Wallis. Resultados: Se incluyeron un total de 60 sujetos con una edad promedio de 66.7 años. El tiempo promedio transcurrido desde el inicio del primer síntoma motor hasta el diagnóstico fue de 20.8 meses. El tener antecedentes familiares de EP se asoció significativamente (p=0.031) con una latencia diagnóstica más prolongada en comparación con aquellos pacientes que no refirieron familiares con EP. En cualquier momento antes del diagnóstico de EP: el 36.6% de los pacientes percibieron estreñimiento, 15% depresión, 13.3% trastorno conductual del sueño MOR y 11.6% disfunción olfatoria, 51.7% no refirió ninguno. Conclusiones: La latencia diagnóstica promedio de un grupo de 60 pacientes con EP diagnosticados en Yucatán fue de 20.8 meses. La latencia diagnóstica no se asoció significativamente con el tipo de servicio médico de neurología que realizó en diagnóstico de EP (público o privado), ni con otras variables clínicas ni demográficas además del antecedente familiar de EP.

Abstract Objective: To determine the diagnostic latency in Parkinson's disease (PD), and its relationship with clinical and demographic variables. To determine the perception of non-motor symptoms: olfactory dysfunction, REM sleep behavior disorder, depression, and constipation, prior to the diagnosis of PD. Materials and methods: Cross-sectional study conducted in Yucatan, Mexico in subjects with PD. The association between diagnostic latency with clinical and demographic variables was analyzed using the non-parametric statistical tests: Mann Whitney U and Kruskal-Wallis. Results: A total of 60 subjects with a mean age of 66.7 years were included. The average time elapsed from the onset of the first sympoton to diagnosis was 20.8 months. A family history of PD was significantly associated (p=0.031) with a longer diagnostic latency compared to those patients who did not have relatives with PD. Before the diagnosis of PD: 36.6% of the patients perceived constipation, 15% depression, 13.3% REM sleep behavior disorder and 11.6% olfactory dysfunction, 51.7% did not report any. Conclusions: The mean diagnostic latency of a group of 60 patients with PD diagnosed in Yucatan was 20.8 months. Diagnostic latency was not significantly associated with the type of neurological medical service that performed the diagnosis (public or private), or with other clinical or demographic variables in addition to a family history of PD.

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Research into assisted living environments -within the area of Ambient Assisted Living (ALL)-focuses on generating innovative technology, products, and services to provide medical treatment and rehabilitation to the elderly, with the purpose of increasing the time in which these people can live independently, whether they suffer from neurodegenerative diseases or disabilities. This key area is responsible for the development of activity recognition systems (ARS) which are a valuable tool to identify the types of activities carried out by the elderly, and to provide them with effective care that allows them to carry out daily activities normally. This article aims to review the literature to outline the evolution of the different data mining techniques applied to this health area, by showing the metrics used by researchers in this area of knowledge in recent experiments.

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BACKGROUND: Adherence to treatment in Parkinson's disease (PD) is compromised due to the need for multiple therapies, comorbidities related to aging, and the complexity of therapeutic schemes. In the present study, we aimed to explore adherence to treatment in groups of PD patients from six Latin-American (LA) countries and identify its associated demographic and clinical parameters. METHODS: A multicenter, cross-sectional, exploratory study was conducted from September 2016 to March 2017. Treatment adherence was assessed using the simplified medication adherence questionnaire (SMAQ), applied to patients and caregivers. Sociodemographic and clinical variables (MDS-UPDRS Part III-IV, MMSE, Beck Depression Inventory-II (BDI-II)) were recorded. RESULTS: Eight hundred patients from six LA countries were evaluated. Nonadherence was reported in 58.25% of the population, according to patients. The most frequent issues were forgetfulness and correct timing of doses. A high level of agreement in adherence prevalence and most SMAQ items were observed between patients and their caregivers. The nonadherent population had a significantly higher proportion of unemployment, free access to medication, troublesome dyskinesias and off-periods, lesser years of education, and worse motor, cognitive, and mood scores. In multiple logistic and linear regression analyses, MDS-UPDRS Part III, BDI-II, gender, free access to medication, treatment with dopamine agonists alone, years of education, excessive concerns about adverse effects, and beliefs about being well-treated remained significant contributors to adherence measures. CONCLUSION: Educational strategies, greater involvement of PD patients in decision-making, and consideration of their beliefs and values might be of great need to improve medication adherence in this PD population.

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This article contains methods, results, and analysis agreed for the development of an application based on the internet of things and making use of machine learning techniques that serves as a support for the identification of the saline wedge in the Magdalena River estuary, Colombia. As a result of this investigation, the process of identifying the most suitable telecommunications architecture to be installed in the estuary is shown, as well as the characteristics of the software developed called SISME (Estuary Monitoring System), and the results obtained after the implementation of prediction techniques based on time series. This implementation supports the maritime security of the port of Barranquilla since it can support decision-making related to the estuary. This research is the result of the project "Implementation of a Wireless System of Temperature, Conductivity and Pressure Sensors to support the identification of the saline wedge and its impact on the maritime safety of the Magdalena River estuary".

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This work presents experiments, modelling and numerical simulation aimed at describing the mechanical response of human ascending aortas in the ring opening test. The objective is to quantify, from the opening angles measured in the test, the residual stress distribution along the artery wall and, afterwards, how this stress pattern changes when the artery is subjected to standard physiological pressures. The cases studied correspond to four groups including both healthy and pathological arteries. The tissues are characterized via tensile test measurements that enable to derive the material parameters of two constitutive models adopted in the present analysis. Overall, the numerical results obtained for all groups were found to be a useful data that allow to estimate the residual stress and their influence on the vessels under normal and hypertension physiological conditions.

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BACKGROUND: Parkinson's disease is characterized by motor and non-motor clinical features. The latter may present as pre-motor symptoms several years before the motor onset. OBJECTIVE: To analyze the association between pre-motor symptoms load and its lead-time in relation to the motor onset and time to diagnosis. METHODS: A cross-sectional study was carried including subjects with Parkinson's disease from five different movement disorders clinics in Mexico. A structured questionnaire was applied to assess the presence of six self-perceived pre-motor symptoms (hyposmia, depression, anxiety, constipation, pain and sleep disorders). RESULTS: Overall frequency of pre-motor symptoms was 76.2% . Among the most prevalent symptoms were depression (38%), sleep disorders (37%) and anxiety (36.6%). The lead time to motor onset was greater for constipation (9.2 ± 17.89 years) and pain (8.66 ± 13.36 years). Patients with more than two pre-motor symptoms had a later age at motor onset when compared to patients without pre-motor symptoms (52.04 ± 13.11 vs 56.55 ± 12.97 years, p = 0.037). Late onset patients had a higher frequency of pre-motor symptoms (79% vs 65% in early onset, p = 0.002) and a higher load (1.75 ± 1.37 vs 1.44 ± 1.38, p = 0.033) in comparison to those with early onset. Female subjects reported a higher number of pre-motor symptoms (1.91 ± 1.43 versus 1.48 ± 1.29, p ≤ 0.001). PIGD patients reported a greater frequency of pain (8%) compared to tremor (1%, p = 0.0064) and bradykinetic-rigid (0.61%, p = 0.0061). Anxiety lead-time was greater in tremor-dominant (10.83 ± 15.77 years) compared to bradykinetic-rigid patients (3.48 ± 12.56, p = 0.014). CONCLUSIONS: Pre-motor symptoms load is associated to a later motor onset of PD. Pre-motor symptoms are more frequent in subjects with late onset Parkinson's disease. Female subjects report a higher number of pre-motor symptoms, depression and anxiety being the most common.

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BACKGROUND: Neuropsychiatric symptoms in Parkinson's disease (PD) are frequent. Impact of neuropsychiatric symptoms on quality of life has recently become a relevant topic of research due to its potential to develop targeted therapies to improve quality of life. OBJECTIVE: To determine the impact of neuropsychiatric symptoms in patients with PD using the Parkinson's Disease Questionnaire Short Form (PDQ-8). METHODS: Consecutive patients with PD were evaluated with the Scale for Evaluation of Neuropsychiatric Disorders in Parkinson's disease (SEND-PD) and PDQ-8 scales separately. Association between neuropsychiatric symptoms and quality of life was explored using, means comparisons, correlation coefficients and multiple regression models. RESULTS: A total of 492 patients were included for the study. Overall, 44.5% had psychotic symptoms, 76.5% had alterations on mood/apathy domains, and 27% had an impulse control disorder. All neuropsychiatric symptoms had an effect on the PDQ-8 with a moderate to large effect size. Correlation coefficients ranged from 0.17 to 0.63 between neuropsychiatric symptoms and quality of life (p <  0.001, in all cases). The regression model showed that mood/apathy alterations and impulse control disorders, along with MDS-UPDRS III accounted for 49.8% of variance in the PDQ-8 simplified index (F = 122.98; p <  0.001). Mood/apathy alterations showed the highest correlation coefficient (0.63, p <  0.001) and ß (0.53, p <  0.001). CONCLUSIONS: Both the presence and severity of neuropsychiatric symptoms, in particular mood/apathy alterations,had a significant impact on quality of life in subjects with PD.

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INTRODUCTION: The European Quality of Life Questionnaire 5 level version (EQ-5D-5L) is a recently updated instrument to assess Health-Related Quality of Life (HRQoL) that has not been validated extensively. The main objective of this study was to evaluate the internal consistency and convergent validation of the EQ-5D-5L in a large sample of subjects with Parkinson's disease (PD). METHODS: A cross-sectional study was carried out. Consecutive Mexican subjects with PD were included. HRQoL was assessed using the EQ-5D-5L and the PDQ-8. Validity of the EQ-5D-5L was assessed determining its association with clinical ratings of disease severity, as well as correlation with PDQ-8. Additionally, performance was evaluated along predefined groups based on clinical and demographic data of known determinants of quality of life. RESULTS: A total of 585 patients were included for this study. A strong correlation was found between EQ-5D-5L index and PDQ-8 index (Spearman's correlation coefficient=-0.75; p<0.001). Correlation between EQ-5D-5L index and PDQ-8 index remained strong (-0.60 to -0.78; p values <0.001) through all predefined groups. EQ-5D-5L scored higher in those patients with dyskinesia, wearing off, freezing, postural instability, cognitive impairment or depressive mood (p values <0.001). CONCLUSION: The EQ-5D-5L is a valid instrument for evaluating HRQoL in PD, performing adequately irrespective of heterogeneous clinical and demographic characteristics, and showing to be sensitive to features of advanced disease and treatment complications.

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Objetivo: Identificar los factores de riesgo en la aparición de multidrogo resistencia en pacientes con tuberculosis en el Hospital Regional de Ica, durante los años 2006 al 2012. Materiales y métodos: La muestra estuvo constituida por 41 casos (tratados por tuberculosis multidrogo-resistente [TB-MDR]) y 82 controles (tratados por tuberculosis sensible [TB]), seleccionados mediante muestreo alea-torio sistemático. Resultados: Se halló tuberculosis pulmonar en 92,7% de los casos y 80,5% de los con-troles; extrapulmonar en 22,4% de los casos y 15,9% de los controles y del tipo mixto en 2,4% en igual porcentaje tanto en los casos como en los controles (p>0,05). En 32 casos (78,0%) y 16 controles (19,5%) tenían antecedente de tratamiento antituberculoso (Chi2 =39.36; p=0,000; OR=14.24; IC95%=5,809-37,480). En 9 casos (22,2%) y 1 control (1,2%) se registró contacto previo con paciente diagnosticado de TB-MDR. (Chi2=13,08; p=0,000; OR=22,2; IC95%=3,451-508,8). Conclusiones: La TB-MDR se presenta con mayor probabilidad cuando existe el antecedente de tratamiento antituberculoso y el contacto con un paciente que es portador de TB-MDR. (AU)

Objective: To identify risk factors in the emergence of multidrug resistance in tuberculosis patients in the Regional Hospital of Ica, during the years 2006 to 2012. Materials and Methods: The sample con-sisted of 41 cases (treated for multidrug-resistant tuberculosis [TB-MDR]) and 82 controls (treated for sensitive tuberculosis [TB]), selected by systematic random sampling. Results: Pulmonary tuberculosis was found in 92.7% of cases and 80.5% of controls; extrapulmonary in 22.4% of cases and 15.9% of controls and mixed type in 2.4% in the same proportion in both cases and controls (p> 0.05). In 32 cases (78.0%) and 16 controls (19.5%) had a history of TB treatment (Chi2 = 39.36; p = 0.000; OR = 14.24; 95% CI = 5.809 to 37.480). In 9 cases (22.2%) and control 1 (1.2%) prior contact with patients diagnosed with MDR-TB was recorded. (Chi2 = 13.08; p = 0.000; OR = 22.2; 95% CI = 3.451 to 508.8). Conclusions: MDR-TB occurs most likely when the history of TB treatment and contact with a patient who is a carrier of MDR-TB exists. (AU)

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BACKGROUND: Plasma cell tumor only rarely affects the cranium and may be found as an isolated lesion or as a part of multiple myeloma. In this review we present the clinical and radiological characteristics and analyze the evolution of two cases of this tumor located at the skull base, specifically in the clivus and sellar region. We also present a brief review of the literature. CLINICAL CASES: Case #1: The patient was a 66-year-old female with a solitary plasmacytoma of the bone (the isolated form of plasma cell tumor) that was totally removed. Case #2: The patient was a 61-year-old male with the diffuse form of this disease who was submitted to subtotal removal. In both patients, adjuvant treatment based on radiotherapy and chemotherapy was proposed; however, only one patient (Case #2) accepted adjuvant treatment and had a very favorable result. Most clinical symptoms disappeared and the patient is currently alive and with a very good quality of life (>3-year follow-up). The other patient (Case #1), despite the presence of the localized form of the disease, died 3 months after diagnosis. CONCLUSION: Early diagnosis and removal of as much of the tumor as possible, but mainly the opportune indication of adjuvant treatment with radiotherapy and chemotherapy, are the keys to management of these cases.

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La disección submucosal endoscópica es una técnica terapéutica prometedora para la resección en bloque de tumores gastrointestinales. Esta técnica tiene sus desventajas, tiempo de intervención largo, complejidad del procedimiento, y tasa de complicaciones. Mostrar la aplicabilidad y seguridad de la Hibrid disección submucosal endoscópica en estómago de cerdos exvivos utilizando dispositivo mecánico para elevar la pieza a disecar. 4 endoscopistas expertos en Hibrid disección submucosal endoscópica en modelos experimentales ex vivos realizaron disección submucosal endoscópica utilizando la técnica Hibrid Knife y dispositivo mecánico por fuera del canal de trabajo para elevar la pieza a disecar. Tiempo de intervención y tasa de complicaciones durante la introducción del dispositivo y la disección submucosal endoscópica (DSE) fue documentada. 11 procedimientos fueron realizados. En los primeros 4 procedimientos, el tiempo promedio de DSE fue 6.5 min (lesiones < 2cms), en los siguientes 4 procedimientos 9.5 min (lesiones entre 2- 3 cms) y en los 3 últimos procedimientos 10.33 min (lesiones > 3 cms). No hubo complicaciones. En nuestro trabajo el uso del dispositivo mecánico pareciera facilitar la técnica Hibrid-DSE haciéndola menos laboriosa, disminuyendo el tiempo y la tasa de complicaciones, se necesitaran estudios in vivo

The endoscopic submucosal dissection is a promising therapeutic technique for bloc resection of gastrointestinal tumors. However, this technique has some disadvantages like long intervention time, complexity of procedure and complications rate. To show the applicability and security of the endoscopic submucosal hybrid dissection in pigs stomach alive, using a mechanical device to lift up the piece to be dissected. 4 endoscopic submucosal hybrid dissection expert physicians, in live experimental models performed the submucosal endoscopic dissection using the Hybrid Knife technique and the mechanical device out of the working channel, in order to lift up the piece to be dissected.The intervention time and difficulty rate during the device introduction and the ESD (Endoscopic Sub mucosal Dissection) were documented. A total of 11 procedures were performed. In the first 4 procedures, the average time of DSE was 6.5 min (lesions < 2cms), in the following 4 procedures 9.5 min (lesions between 2 to 3 cm) and in the last 3 procedures was 10.33 min (lesions > 3 cm). There were no complications. In our work, to use the mechanical device seems to ease the Hybrid ESD, making it less difficult, diminishing time and complication rates. Live study will be necessary

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Los dos principales tipos de pólipos en el colon son los adenomas y los pólipos hiperplásicos. La imagen de banda estrecha (NBI) es una tecnología que mejora la visualización de los patrones vasculares en la superficie del pólipo pudiendo ayudar a diferenciar entre adenomas y los pólipos hiperplásicos con un alto grado de precisión. Este estudio pretende evaluar la diferencia y variabilidad inter e intraobservador, antes y después de una clase didáctica de puntos claves sobre las imágenes de banda estrecha para su entendimiento, diferenciación y reconocimiento. 14 gastroenterólogos y se seleccionaron 50 imágenes de pólipos hiperplasicos y adenomas verificados por estudio histológico. El puntaje de incremento en la adecuada identificación de las lesiones varió entre 37,86% a 78,57%. En esta evaluación inicial se mostró que los hallazgos dados con el uso de NBI son reproducibles, fáciles de aprender, bastante exactos, y tienen un alto potencial para su uso en la práctica clínica diaria permitiendo la caracterización en tiempo real de los pólipos en colon

The 2 main types of colon polyps are adenomas and hyperplastic. Narrow band imaging (NBI) is a novel technology that enhances the visualization of surface mucosal and vascular patterns on the polyp surface. The patterns seen on the polyp surface with NBI that can help differentiate between adenomas and hyperplastic polyps with a high degree of accuracy. The aim of this study was to evaluate the interobserver and intraobserver agreement (among endoscopists). 14 gastroenterologists and 50 images were selected hyperplastic polyps and adenomas verified by histology. The score of increase in the effective identification of lesions ranged from 37.86% to 78.57%. This initial evaluation showed that the NBI polyp patterns described in our pilot study are reproducible, easy to learn, reasonably accurate, and have the potential for use in daily clinical practice for the realtime differentiation of colon polyps

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El cáncer gástrico precoz, se diagnostica cada día con más frecuencia no solo en Japón sino en todo el mundo y, aunque su tratamiento endoscópico es relativamente sencillo, en nuestro medio hay poca experiencia sobre la resección de lesiones sospechosas. El pronóstico de cáncer gástrico temprano es muy bueno y la tasa de supervivencia a los 5 años es del 90%. Por ello, basado en el criterio del tratamiento temprano de cáncer gástrico tiene mejor pronóstico, es importante la detección temprana masiva esta enfermedad antes de que evolucione a un estado avanzado.

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El Tegaserod es un agonista parcial selectivo de los receptores de 5-hidroxitritamina-4 (5-HT4). No tiene ninguna afinidad significativa por receptores muscarínicos, histamina-H1 adrenérgico, dopaminérgico o receptores opiáceos. Esta selectividad explica parcialmente su perfil con escasos efectos colaterales. La administración oral del Tegaserod causa efectos gastrointestinales que resultan en aumento de la motilidad gastrointestinal y atenuación de las sensaciones viscerales. Determinación la Seguridad y la Eficacia del Tegaserod en pacientes con Constipación Crónica. Estudio Prospectivo, Aleatorio, Ciego y Controlado con Placebo con dosis de 6 mg de Tegaserod vía oral cada 12 horas administrado 30 minutos ante de las comidas, en pacientes femeninas no embarazadas con rango de edad entre 18-45 años, provenientes de la consulta externa y con criterios de Constipación Crónica Funcional, durante un período de 27 meses. Las pacientes fueron asignadas en forma aleatorea a dos grupos: Grupo T: Tegaserod, dieta y ejercicio y Grupo P: Placebo BID dieta y ejercicio. Cada grupo fue seguido por un mínimo de 16 semanas. Un total de 209 pacientes del sexo femenino con diagnostico de Constipación Crónica fueron tratadas con Tegaserod. De estas solo 119 (56.93 por ciento) terminaron el estudio, 59 pacientes del Grupo A y 60 pacientes del Grupo B. El efecto colateral más frecuente relacionado con el Tegaserod fue diarrea, la cual fue leve y transitoria (7.1 por ciento) seguido por dolor abdominal (6.1 por ciento) dolor de cabeza (5.3 por ciento) y flatulencia (4.6 por ciento). Los efectos colaterales más frecuentes con el grupo placebo fueron: Dolor de cabeza (5.0 por ciento), Flatulencia (3.5 por ciento) Dolor abdominal (2.9 por ciento), Diarrea (2.1 por ciento) y Nauseas (1.1 por ciento). No se reportaron efectos adversos serios. Tampoco se observaron anormalidades relaciones con el Tegaserod en los valores de laboratorio hematológicos ni bioquímicos, examen de orina...

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Se propuso la caracterización de 14 cepas de Shigella boydii 14 aisladas de pacientes con enfermedad diarreica aguda mediante sus plásmidos de resistencia y de las proteínas de la membrana externa presentes en ellas. Se realizó la determinación de la susceptibilidad antimicrobiana por el método de concentración mínima inhibitoria, la extracción de plásmidos R fue según Manaitis, los extractos proteicos de las cepas se obtuvieron según el método de Blaser modificado y las proteínas de la membrana externa fueron separadas por SDS-PAGE por el método de Laemmli. Se comprobó que las cepas resultaron resistentes a la ampicilina (100 porciento), la tetraciclina (70 porciento) y al cotrimoxazol (50 porciento), y sensibles al ácido nalidíxico y a la ciprofloxacina. Se observó la presencia de plásmidos al nivel de los 43; 23; 20; 5,6 y 1,2 kb. Las proteínas de la membrana externa y el perfil proteico demostraron diferencias con otras especies de Shigella. Este serotipo de Shigella se aísla por primera vez en Cuba y y sus características la hacen altamente patógena y de muy difícil diagnóstico, por lo que la caracterización de este brote es importante desde el punto de vista epidemiológico

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La desnutrición infantil continúa siendo uno de los principales problemas de salud pública en los países preindustrializados, y no se percibe por ahora tendencia alguna hacia la disminución del número de niños afectados. Resulta pertinente difundir así sea en forma resumida, las principales características de la desnutrición infantil, como la etiología a nível individual y colectivo, su concepto, diagnóstico, clasificación y tratamiento integral en ambientes hospitalario. Se hacen consideraciones acerca de la prevención del padecimiento y se poroponen alternativas de acción para realizar estudios epidemiológicos, utilizando indicadores que permitan determinar la probabilidad del riesgo de desnutrición que tiene una persona o un grupo, así como de sufrir daño o prsentar una condición desfavorable en presencia de factores nocivos fácilmente identificables y estudios que posteriormente permitan o ayuden a extender la cobertura de servicios a bajo costo

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