• Prevalence of severe acute respiratory syndrome Coronavirus 2 antibodies among market and city bus depot workers in Lima, Peru

      Tovar, Marco; Peinado, Jesús; Palomino, Santiago; Llanos, Fernando; Ramírez, Claudio; Valderrama, Gisella; Calderón, Roger I.; Williams, Roger B.; Velásquez, Gustavo E.; Mitnick, Carole D.; Franke, Molly F.; Lecca, Leonid (NLM (Medline), 2022-01-29)
      We report severe acute respiratory syndrome coronavirus 2 antibody positivity among market and city bus depot workers in Lima, Peru. Among 1285 vendors from 8 markets, prevalence ranged from 27% to 73%. Among 488 workers from 3 city bus depots, prevalence ranged from 11% to 47%. Self-reported symptoms were infrequent.
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    • Prevalence of venous thromboembolism in admissions and readmissions with and without syncope: A nationwide cohort study

      Kadri, Amer N.; Zawit, Misam; Al-Adham, Raed; Hader, Ismail; Nusairat, Leen; Almahmoud, Mohamed F.; Senussi, Mourad; Altibi, Ahmed; Barakat, Amr; Hernandez, Adrian V.; Masri, Ahmad (Oxford University Press, 2021-01-01)
      Aims: The Pulmonary Embolism in Syncope Italian Trial reported 17.3% prevalence of pulmonary embolism (PE) in patients admitted with syncope. We investigated the prevalence of venous thromboembolism [VTE, including PE and deep vein thrombosis (DVT)] in syncope vs. non-syncope admissions and readmissions, and if syncope is an independent predictor of VTE. Methods and results: We conducted an observational study of index admissions of the 2013-14 Nationwide Readmission Database.
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    • Prevalencia de Helicobacter pylori en pacientes sintomáticos de consulta externa de la Red Rebagliati (EsSalud), Lima, Perú, en el período 2010 - 2013

      Castillo Contreras, Ofelia; Maguiña Quispe, Jorge; Benites Goñi, Harold; Chacaltana Mendoza, Alfonso; Guzmán Calderón, Edson; Dávalos Moscol, Milagros; Frisancho Velarde, Oscar (Sociedad de Gastroenterología del Perú (SGP), 2016-03)
      Objetivo: Determinar la prevalencia de Helicobacter pylori en pacientes sintomáticos de consulta externa en la Red Rebagliati (EsSalud) en el período 2010-2013. Materiales y métodos: Estudio observacional, transversal y analítico. Se revisaron los registros de pacientes ambulatorios con la prueba en aliento con urea-13C diagnóstica de Helicobacter pylori en el período 2010-2013. Resultados: De los 1711 pacientes, la prevalencia global de Helicobacter pylori fue 45,5% (IC 95%: 43,17- 47,89), siendo mayor en mujeres que en varones (47,1% vs. 42,1%, p=0,056). Hubo diferencias significativas en la edad entre infectados y no infectados (44 vs. 39, p<0,05), con asociación entre la edad y presencia de Helicobacter pylori (p<0,001). La prevalencia estimada en la población pediátrica fue 36,3% y se encontró resultado positivo en 201 (51,1%) mujeres en edad fértil. La mayoría (43,9%) procedían del sector financiero de la ciudad. Conclusiones: La prevalencia de Helicobacter pylori en la población de estudio fue similar en ambos sexos y tuvo relación con la edad. El nivel socioeconómico medio de Lima mantiene la prevalencia de Helicobacter pylori reportada en los últimos años.
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    • Prevalencia del Síndrome de Burnout en médicos y enfermeras del Perú, ENSUSALUD 2014

      Maticorena Quevedo, Jesús; Beas, Renato; Anduaga Beramend, Alexander; Mayta-Tristan, Percy; [email protected] (Instituto Nacional de Salud (INS), 2016-03)
      Objectives. To determine the difference in the prevalence of burnout syndrome (BS) using different cut-off points for each scales in physicians and nurses of Peru in 2014. Materials and Methods. A cross-sectional, descriptive study of secondary data based from the National Health-User Satisfaction Survey 2014 (in Spanish: Encuesta Nacional de Satisfacción de Usuarios en Salud - 2014, ENSUSALUD 2014). The BS was identified through the Maslach Burnout Inventory - Human Services Survey (MBI-HSS) using different cut-off points to establish its prevalence: default values, tertiles and quartiles. Results. Of the 5067 health professionals, 62.3% were women, 44.0% were physicians, 46.0% belonged to the Ministry of Health (MINSA), and 23.1% worked in Lima. An overall prevalence of SB 2.8% (CI95%: 2,19-3,45) was obtained using default values; 7.9% (CI95%: 6,93-8,95) according to quartiles; and 12.5% (CI95%:11,29- 13,77) using tertiles. Prevalence found was higher in physicians than nurses regardless of the cut-off points used (3.7% vs 2.1% in default values; 10.2% vs 6.1% using quartiles, and 16.2% vs 9.5% by tertiles).Conclusions. Prevalence of BS in health workers was different in the same population according to different cut-off points. We recommended using default values established by the author of the instrument until it is obtained specific cut-off points for our country.
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    • Prevalencia y factores asociados a la sintomatología depresiva en mujeres con cáncer de mama en un hospital público de Lima, Perú

      Berrospi-Reyna, Silvia; Herencia-Souza, Mónica; Soto, Alonso; [email protected] (Colegio Médico del Perú (CMP), 2017-04)
      Objective: To assess the prevalence and the associated factors with depressive symptoms in women diagnosed with breast cancer. Materials and methods: This is a cross-sectional study performed in a hospital in Lima, Peru. We used the Patient Health Questionnaire scale (PHQ-9) for assessing the presence of depressive symptoms. Results: We recruited 385 patients, and we found a 21.29% prevalence of depressive symptoms. The mean age of patients was 59.56 years, with no statistically significant differences between age groups with or without depressive symptoms. Bivariate analyses showed statistically significant associations between depressive symptoms and educational level, dyspnea, insomnia, pain, gastrointestinal symptoms, general symptoms, radiotherapy use and monthly income. However, multivariate analyses showed there was a statistically significant association only between depressive and gastrointestinal symptoms (odds ratio: 2.94; 95% confidence interval: 1.48–5.83, p<0.01). Conclusions: Women with breast cancer have a high frequency of depressive symptoms, and these are associated to the presence of gastrointestinal symptoms. We recommend to systematically screen for depressive symptoms in these patients and to offer them multidisciplinary management for their condition.
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    • Prevalencia y factores asociados con la filariosis por Mansonella ozzardi en 2 comunidades periurbanas de Iquitos, 2009

      Arróspide, Nancy; Reyna, Óscar; Montenegro Drogob, Juan José; Palominoa, Miriam; Lucero, Jorge; Villaseca, Pablo; León, Walter; Valenciaa, Pedro; Mayta-Tristan, Percy (Elsevier B.V., 2015-05-15)
      Introducción Tres casos de infección por Mansonella ozzardi (M. ozzardi) en muestras de malaria que provenían de 2 comunidades periurbanas de Iquitos (Perú) dieron la sospecha de transmisión local. El objetivo del estudio fue determinar la prevalencia y factores asociados con la filariosis por M. ozzardi en estas comunidades. Materiales y métodos Se realizó un estudio transversal en las comunidades de Laguna Azul y La Unión en Iquitos. A todos los pobladores se les tomó una gota gruesa para la detección de M. ozzardi y se les realizó una encuesta epidemiológica. Se realizó colecta de larvas y mosquitos para identificación de potenciales vectores. Se calcularon los OR ajustados (ORa) usando regresión logística múltiple. Resultados Se evaluaron a 433 personas; 58% fueron mujeres; la mediana de edad fue de 20 años; 58,2% fueron migrantes, 3,7% pescadores y 12,9% habían viajado por las cuencas del Alto Nanay. La prevalencia de M. ozzardi fue de 1,4% (6/433) y el más joven de los casos tuvo 31 años; se encontró asociación con ser pescador (ORa: 8,7; IC 95: 1,1-76,0) y con haber realizado viajes por la cuenca del Alto Nanay (ORa: 11,2; IC 95: 1,2-112,5). No se evidenció densidad significativa de vectores simúlidos o culicoides. Conclusión Las comunidades estudiadas tuvieron una baja prevalencia de M. ozzardi y por la edad de los casos y los factores asociados encontrados se sospecha infección foránea a la zona de estudio, en especial en la cuenca del Alto Nanay.
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    • Prevalencia y factores asociados con síntomas depresivos en estudiantes de ciencias de la salud de una Universidad privada de Lima, Perú 2010*.

      Pereyra Elías, Reneé; Ocampo-Mascaró, Javier; Silva-Salazar, Vera; Vélez-Segovia, Eduardo; Da Costa-Bullón, A. Daniel; Toro-Polo, Luis Miguel; Vicuña-Ortega, Joanna (Instituto Nacional de Salud (INS), 2014-03-21)
      Introduction. Depressive symptoms in health sciences students are common, these might be potentially detrimental. Objectives. To determine the prevalence of depressive symptoms and its associated factors in students from the Health Sciences Faculty of the Universidad Peruana de Ciencias Aplicadas in Lima (Peru), June 2010. Materials and methods. Cross-sectional analytic study; a pre-consented survey was applied to the population 590/869 students. Zung’s abbreviated scale was used to measure depressive symptoms. To evaluate de associated factors, logistic regression was used, p<0.05 was considered statistically significant. Results. The mean age was 18.97 ± 2.45 years and 71.1% were women, 19.6% were migrants and 62.5% were medical students. The prevalence of depressive symptoms was 31.2% in the whole population and in medical students was 33.6%. Depressive symptoms were not associated in bivariate analysis with sex, career, having failed a course, living alone or being a migrant (p>0.05). In the multivariate analysis, significant statistical association was found between depressive symptoms and dissatisfaction with the own academic performance (OR=2.13 CI95%1.47-3.08), dissatisfaction with the current economic status (OR=1.93 CI95%1.24-2.99) and living with a relative external to the nuclear family (OR=1.62 CI95%1.07-2.45). Conclusion. A high prevalence of depressive symptoms was found, especially in medical students; being dissatisfaction with academic performance, economic status and living with a relative external to the nuclear family associated factors that could be taken into account in order to build preventive programs.
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    • Prevention and control practices against Sars-Cov2 infection in the peruvian population

      Fernandez-Guzman, Daniel; Soriano-Moreno, David R.; Ccami-Bernal, Fabricio; Rojas-Miliano, Cristhian; Sangster-Carrasco, Lucero; Hernandez-Bustamante, Enrique A.; Zamora-Huaringa, Elvira G.; De-Los-Rios-Pinto, Abraham; Nieto-Gutierrez, Wendy (Medical Body of the Almanzor Aguinaga Asenjo National Hospital, 2021-10-21)
      Objetive: To describe the prevention and control practices for the infection to SARS-COV2 in the Peruvian population. Material and Methods: Observational descriptive study. We evaluated a non-probabilistic sample of adult residents in some departments of Peru. Preventive practices were evaluated in people without a history of COVID-19 and control practices in people who had suffered it. Results: We evaluated 3630 Peruvians (mean age 25.4 ± 9.5), of that 3231 don't have a history of COVID-19 and 399 who had suffered it. The prevention and control practices that were realized often or always, with more frequencies, was the use of a mask when they go out home (97.9% vs 87.7), cover their nose or mouth when they sneeze (95.4% vs 89.9%), save the distance to other people in the street (91.4% vs 74.7%), wash their hands when they came home (92.5% vs 88.7%), and disinfect the objects and personal places (82.6% vs 77.4%). The 22.1% and 83.7%, the 59.7% and 80.2, and the 8.0% and 16.8% consumed some type of medicine, medicinal plant, and chlorine dioxide to prevent and control the infection, respectively. Conclusion: In general, less than 50% of the participants performed prevention and control practices against COVID-19 often or always.
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    • Preventive effect of Oenothera rosea on N-methyl-N-nitrosourea- (NMU) induced gastric cancer in rats

      Almora Pinedo, Yuan; Arroyo-Acevedo, Jorge Luis; Herrera-Calderon, Oscar; Chumpitaz Cerrate, Victor Manuel; Hañari Quispe, Renán; Tinco Jayo, Johnny Aldo; Franco Quino, Cesar; Figueroa Salvador, Linder (Dove Medical Press Ltd, 2017-12)
      Background: Currently, gastric cancer (GC) is considered a public health problem worldwide. Using medicinal plants for the prevention of chronic diseases such as cancer constitutes new alternatives in traditional medicine. Oenothera rosea (OR) could be an option, but it needs to be evaluated. Aim: The main objective of this study was to evaluate the protective effect of OR extract on N-methyl-N-nitrosourea (NMU)-induced GC in rats. Methods: In total, 80 male Holtzman rats were randomized into five groups. Group A received the saline solution (5mL/kg), group B received NMU 500 μg/kg (cancer inductor) by oral administration for 16 weeks, and groups C, D, and E were treated with OR extract (100, 200, and 300 mg/kg, respectively) and NMU in order to evaluate the preventive effect on cancer induced by NMU for 16 weeks. Blood and histological samples of stomachs were collected to determine histopathological, biochemical, and hematological parameters between different experimental groups. Results: Groups C, D, and E presented less histopathological changes such as anaplastic and hyperplastic cells, compared with group B. Hematological and biochemical parameters were recorded, and superoxide dismutase, malondialdehyde, and nitric oxide levels were statistically less than those of NMU group (P<0.05, P<0.01, and P<0.01). Conclusion: Considering the histopathological signs and the antioxidant activity in vivo as well as hematological and biochemical parameters of ethanolic extract of OR, we concluded that its administration in rats has a protective effect on GC, which is induced experimentally. This species could be studied in clinical trials for patients with GC in the future.
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    • Primer encuentro subregional de editores de revistas científicas estudiantiles en ciencias de la salud, Arequipa, Perú, 2014

      Clouet Huerta, Diego E.; Mejia, Miluska O.; Carvajal Tapia, Aaron E.; Mayta-Tristan, Percy; Rodríguez-Morales, Alfonso J. (Sociedad Médica de Santiago, 2014-11-27)
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    • PRISM como predictor de mortalidad en la unidad de cuidados intensivos pediátricos del Instituto Nacional de Salud del Niño, Perú 2012

      Vásquez, Aida; Herrera-Perez, Eder; Tantaleán, José; Escalante Kanashiro, Raffo; [email protected] (Colegio Médico del Perú (CMP), 2016-03)
      Introducción: La escala de PRISM es un predictor de mortalidad pediátrico que considera el riesgo de morir a partir del grado de afectación de 14 parámetros fisiológicos. Éste ha sido aplicado en diferentes partes del mundo, mostrando algunas discrepancias en su poder predictivo. Objetivos: Evaluar el rendimiento del escore PRISM como predictor de mortalidad de los pacientes hospitalizados en la Unidad de Cuidados Intensivos Pediátricos (UCIP) del Instituto Nacional de Salud del Niño (INSN) en Lima, Perú. Material y Método: Se analizó la base de datos de pacientes ingresados a la UCIP-INSN durante el año 2012. Se calculó la curva ROC como medida de capacidad discriminativa. La calibración fue evaluada con la prueba de Hosmer y Lemeshow. También se calculó la tasa de mortalidad estandarizada (TME). Resultados: De un total de 388 casos el 17,3% fallecieron. Según escore de PRISM, el 91,1% tuvo un “bajo riesgo”, el 7,1% un “moderado riesgo” y el 1,8% “alto riesgo”. Se encontró asociación entre las categorías del PRISM y mortalidad (p<0,001). La curva ROC para PRISM fue 0,73 (IC95%: 0,66-0,80), la TME fue 1,01 y la calibración fue buena (p=0,65). Conclusiones: El escore PRISM muestra un rendimiento adecuado como predictor de mortalidad.
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    • Probiotics for treating persistent diarrhoea in children

      Bernaola Aponte, Guillermo; Alfonso Bada Mancilla, Carlos; Carreazo, Nilton Yhuri; Rojas Galarza, Raúl Alberto (The Cochrane Collaboration. Published by John Wiley & Sons, Ltd., 2014-03-07)
      Background Persistent diarrhoea (diarrhoea lasting more than 14 days) accounts for one third of all diarrhoea related deaths in developing countries in some studies. Probiotics may help treatment. Objectives To evaluate probiotics for treating persistent diarrhoea in children. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, EMBASE, and LILACS. We also contacted authors of included trials and organizations working in the field, and checked reference lists. The date of the most recent search was 13 December 2012 Selection criteria Randomized controlled trials comparing a specified probiotic agent with placebo or no probiotic in children with persistent diarrhoea. Data collection and analysis Two review authors assessed the eligibility, risk of bias, extracted and analysed data. Differences were resolved by discussion. Statistical analysis were performed using the fixed-effect model and the results were expressed as mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). Main results Four trials were included, with a total number of 464 participants; one trial had a low risk of bias. Meta-analysis showed that probiotics reduced the duration of persistent diarrhoea (mean difference 4.02 days, 95%CI 4.61 to 3.43 days, n = 324, two trials). Stool frequency was reduced with probiotics in two trials. One trial reported a shorter hospital stay, which was significant, but numbers were small. No adverse events were reported.
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    • Probióticos, prebióticos y simbióticos en el síndrome de intestino irritable

      Guzmán Calderón, Edson; Montes Teves, Pedro; Monge Salgado, Eduardo (Colegio Médico del Perú, 2014-07-16)
      El síndrome del intestino irritable es un trastorno común que afecta a millones de personas en todo el mundo. Dicho transtorno tiene un impacto significativo en la calidad de vida de las personas que lo padecen afectando en mayor o menor medida la esfera sociolaboral de estos individuos con el consecuente sufrimiento individual e impacto macroeconómico por aumento en las tasas de ausentismo y rendimiento laboral. Los prebióticos y probióticos son suplementos de la dieta no digerible, elementos químicos y microorganismos vivos (bacterias o levaduras de la flora comensal intestinal) que al consumirlos en volúmenes óptimos (tratamiento simbiótico), resultan beneficiosos para la salud humana. La mucosa intestinal es sin duda la mayor superficie del organismo humano expuesta al medio externo, ademas de contener una alta densidad de células inmunitarias. La alteración de la homeostasis entre los microorganismos beneficiosos y potencialmente nocivos de la microflora intestinal se expresa en un incremento del riesgo a padecer infecciones y enfermedades inmunoinflamatorias y, en este sentido, los pre y probióticos ayudan a mantener esta armonía.
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    • Problemas en la prescripción médica para el adulto mayor en Perú.

      Rodríguez, Nelson; Puente, Iris; Bernabe-Ortiz, Antonio (Instituto Nacional de Salud (INS), 2014-03-19)
      Cartas al editor.
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    • Problematic smartphone use is associated with de Quervain's tenosynovitis symptomatology among young adults

      Benites-Zapata, Vicente Aleixandre; Jiménez-Torres, Vanesa Esmeralda; Ayala-Roldán, María Pía (Elsevier Ltd, 2021-06-01)
      Background: Previous research has reported an association between texting messages sent and De Quervain's tenosynovitis (DQT) symptomatology. However, these studies do not report smartphone dependence and DQT symptomatology. Objective: We aimed to evaluate the association between problematic smartphone use (PSU) and DQT symptomatology among young adults. Design: Analytical cross-sectional study. Methods: We included adults between 18 and 25 years and evaluated DQT symptomatology's presence using the Finkelstein test. We used Experiences Related to Mobile Phone Use Questionnaire to measure the PSU. We carried out a generalized linear model from the Poisson family. We calculated the crude and adjusted prevalence ratios (PR) with their 95% confidence interval (CI). Results: In total, we analyzed 491 subjects, the majority were women (52%), and the median age was 20 years. Of the total study population, 53% had positive results in the Finkelstein test, while 53% of the population had PSU. After adjusting our generalized linear model for confounders variables, we found that there is a higher prevalence of DQT symptomatology in those participants with occasional PSU and frequent PSU compared with participants without PSU, (aPR = 1.73, 95% CI: 1.47–2.05) and (aPR = 1.61; 95% CI: 1.29–2.00); respectively. We also found a higher prevalence of DQT symptomatology related to the number of hours per day in smartphones, pain with smartphones in the last week and using WhatsApp. Conclusion: We found a higher prevalence of De Quervain's tenosynovitis symptomatology in the people with problematic smartphone use.
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    • Problems perceived and experienced by health professionals rendering social service in Ancash, Peru. 2015

      Taype-Rondán, Álvaro; Vidal-Torres, María Isabel; Chung-Delgado, Kocfa; Maticorena-Quevedo, Jesús; Mayta-Tristan, Percy (Universidad Nacional de Colombia, 2017-07-01)
      Introducción. En Perú, durante el servicio social en salud se han reportado problemas como condiciones laborales riesgosas, mortalidad asociada a accidentes de tránsito y déficit de cobertura de aseguramiento.Objetivo. Describir los problemas percibidos y experimentados por los profesionales de salud que realizan el Servicio Rural y Urbano Marginal de Salud (SERUMS) en Ancash, Perú, y evaluar su asociación con la práctica de los profesionales y la categoría del establecimiento donde se realiza el SERUMS.Materiales y métodos. Durante abril del 2015, se realizó un estudio transversal analítico con profesionales de salud que realizaban el SERUMS en establecimientos del Ministerio de Salud de Ancash. Se aplicaron encuestas para recolectar datos generales, características y problemas del SERUMS.Resultados. Se analizaron 364 encuestas. El 79.3% de los participantes fue de sexo femenino, la edad promedio fue de 27.4±5.0 años, 80.0% percibió carencia de insumos, 54.4% percibió carga laboral excesiva, y 14.7% sufrió algún accidente de tránsito durante el SERUMS. Ser médico y laborar en establecimientos I-1 fueron factores asociados a haber sufrido accidentes de tránsito y otros imprevistos.Conclusiones. Los encuestados reportan carga laboral excesiva, carencia de insumos y accidentes. Los accidentes son más frecuentes en médicos y en establecimientos de categoría I-1.
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    • Producción científica de los decanos de las facultades de medicina en Perú

      Valenzuela Rodríguez, Germán; Herrera Añazco, Percy; Hernández, Adrian V. (Instituto Nacional de Salud Pública, 2015-11-24)
      Cartas al editor
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    • Producción científica de los miembros vitalicios de la Academia Nacional de Investigadores Médicos.

      Mayta-Tristan, Percy; Pereyra Elías, Reneé; Mejía, Christian R. (Instituto Nacional de Salud (INS), 2014-03-25)
      Cartas al editor.
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    • Producción científica y redes de colaboración en cáncer en el Perú 2000-2011: Un estudio bibliométrico en Scopus y Science Citation Index

      Mayta-Tristan, Percy; Huamaní, Charles; Montenegro Idrogo, Juan José; Samanez Figari, César; González Alcaide, Gregorio (Instituto Nacional de Salud (INS), 2014-01-10)
      A bibliometric study was carried out to describe the scientific production on cancer written by peruvians and published in international health journals, as well as to assess the scientific collaboration networks. It included articles on cancer written in Peru between the years 2000 and 2011 and published in health journals indexed in SCOPUS or Science Citation Index Expanded. In the 358 articles identified, an increase in the production was seen, from 4 articles in 2000 to 57 in 2011.The most studied types were cervical cancer (77 publications); breast cancer (53), and gastric cancer (37). The National Institute of Neoplastic Diseases (INEN) was the most productive institution (121 articles) and had the highest number of collaborations (180 different institutions). 52 clinical trials were identified, 29 of which had at least one author from INEN. We can conclude that, cancer research is increasing in Peru, the INEN being the most productive institution, with an important participation in clinical trials.
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    • Profile and professional expectations of medical students from 11 Latin American countries: the Red-LIRHUS project

      Mayta-Tristan, Percy; Pereyra Elías, Reneé; Montenegro-Idrogo, Juan José; Mejia, Christian R.; Inga Berrospi, Fiorella; Mezones-Holguín, Edward (Biomed Central Ltd, 2017-04-20)
      Background Latin America is undergoing a human resource crisis in health care in terms of labor shortage, misdistribution and poor orientation to primary care. Workforce data are needed to inform the planning of long-term strategies to address this problem. This study aimed to evaluate the academic and motivational profile, as well as the professional expectations, of Latin American medical students. Results We conducted an observational, cross-sectional, multi-country study evaluating medical students from 11 Spanish-speaking countries in 2011–2012. Motivations to study medicine, migration intentions, intent to enter postgraduate programs, and perceptions regarding primary care were evaluated via a self-administered questionnaire. Outcomes were measured with pilot-tested questions and previously validated scales. A total of 11,072 valid surveys from 63 medical schools were gathered and analyzed. Conclusions This study describes the profile and expectations of the future workforce being trained in Latin America. The obtained information will be useful for governments and universities in planning strategies to improve their current state of affairs regarding human resources for health care professions.
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