The potential of a mindfulness-enhanced, integrative neuropsychotherapy program for treating fatigue following stroke: A preliminary Study

Fatigue is a frequently reported symptom after a stroke. Although the phenomenology of poststroke fatigue is well known, clear definitions as well as diagnostic and therapeutic guidelines are missing. Poststroke fatigue can be regarded as a multidimensional phenomenon that might be influenced by neurological, physical, psychological, and cognitive factors. It can range from mild to severe and can affect every area of the activities of daily life. The objective of our preliminary study was to outline aspects of a specific treatment program for the management of poststroke fatigue. Eight patients were recruited for a mindfulness-enhanced, integrative neuropsychotherapy program. The treatment was a combination of neuropsychological interventions, psychoeducation, cognitive-behavioral therapy, and mindfulness techniques. The main treatment foci were (a) to facilitate an increased awareness of fatigue symptoms, (b) to help the patient detect and manage triggers of fatigue, and (c) to equip the patient with multiple self-help tools. Measures were assessed at the beginning, during, and at the end of treatment using self-assessment questionnaire for mental fatigue and related symptoms after neurological disorders and injuries. Significant pre- to post-assessment differences were observed. These findings suggest that patients may benefit from a specific treatment program in order to better adapt to poststroke fatigue. These findings encourage further investigation of this integrative treatment in larger samples that include adequate control treatments.

Strategic Incentives in Unconventional Electoral Systems: Introduction to the Special Issue

The study of strategic behaviour and the impact of institutions on elections has mainly focused on simple and conventional electoral systems: list-proportional electoral systems (PR) and the plurality vote. Less conventional systems are not on the agenda of comparative studies, even though no less than 30% of countries use unconventional electoral systems for their national parliamentary elections, such as the Single Transferable Vote, PR with majority bonuses, or mixed electoral systems. Often, they provide for unusual combinations of different institutional incentives, and hence to particular actor strategies.

Partial lateralization of the nasopalatine nerve at the incisive foramen for ridge augmentation in the anterior maxilla prior to placement of dental implants: a retrospective case series evaluating self-reported data and neurosensory testing

The objective of this study was to assess implant therapy after a staged guided bone regeneration procedure in the anterior maxilla by lateralization of the nasopalatine nerve and vessel bundle. Neurosensory function following augmentative procedures and implant placement, assessed using a standardized questionnaire and clinical examination, were the primary outcome variables measured. This retrospective study included patients with a bone defect in the anterior maxilla in need of horizontal and/or vertical ridge augmentation prior to dental implant placement. The surgical sites were allowed to heal for at least 6 months before placement of dental implants. All patients received fixed implant-supported restorations and entered into a tightly scheduled maintenance program. In addition to the maintenance program, patients were recalled for a clinical examination and to fill out a questionnaire to assess any changes in the neurosensory function of the nasopalatine nerve at least 6 months after function. Twenty patients were included in the study from February 2001 to December 2010. They received a total of 51 implants after augmentation of the alveolar crest and lateralization of the nasopalatine nerve. The follow-up examination for questionnaire and neurosensory assessment was scheduled after a mean period of 4.18 years of function. None of the patients examined reported any pain, they did not have less or an altered sensation, and they did not experience a "foreign body" feeling in the area of surgery. Overall, 6 patients out of 20 (30%) showed palatal sensibility alterations of the soft tissues in the region of the maxillary canines and incisors resulting in a risk for a neurosensory change of 0.45 mucosal teeth regions per patient after ridge augmentation with lateralization of the nasopalatine nerve. Regeneration of bone defects in the anterior maxilla by horizontal and/or vertical ridge augmentation and lateralization of the nasopalatine nerve prior to dental implant placement is a predictable surgical technique. Whether or not there were clinically measurable impairments of neurosensory function, the patients did not report them or were not bothered by them.

The Skip To Breakfast project: Development, implementation, and feasibility evaluation of an intervention to increase healthful breakfast consumption among fifth grade students and their families

Children and adults frequently skip breakfast and rates are currently increasing. In addition, the food choices made for breakfast are not always healthy ones. Breakfast skipping, in conjunction with unhealthy breakfast choices, leads to impaired cognitive functioning, poor nutrient intake, and overweight. In response to these public health issues, Skip To Breakfast, a behaviorally based school and family program, was created to increase consistent and healthful breakfast consumption among ethnically diverse fifth grade students and their families, using Intervention Mapping™. Four classroom lessons and four parent newsletters were used to deliver the intervention. For this project, a healthy, "3 Star Breakfast" was promoted, and included a serving each of dairy product, whole grain, and fruit, each with an emphasis on being low in fat and sugar. The goal of this project was to evaluate the feasibility and acceptability of the intervention. A pilot-test of the intervention was conducted in one classroom, in a school in Houston, during the Fall 2007 semester. A qualitative evaluation of the intervention was conducted, which included focus groups with students, phone interviews of parents, process evaluation data from the classroom teacher, and direct observation. Sixteen students and six parents participated in the study. Data were recorded and themes were identified. Initial results showed there is a need for such programs. Based on the initial feedback, edits were made to the intervention and program. Results showed high acceptability among the teacher, students, and parents. It became apparent that students were not reliably getting the parent newsletters to their parents to read, so a change to the protocol was made, in which students will receive incentives for having parents read newsletters and return signed forms, to increase parent participation. Other changes included small modifications to the curriculum, such as, clarifying instructions, changing in-class assignments to homework assignments, and including background reading materials for the teacher. The main trial is planned to be carried out in Spring 2008, in two elementary schools, utilizing four, fifth grade classes from each, with one school acting as the control and one as the intervention school. Results from this study can be used as an adjunct to the Coordinated Approach To Child Health (CATCH) program. ^

The Texas driver responsibility program: A preliminary analysis of the impact on impaired driving and trauma system funding

Objective. In 2003, the State of Texas instituted the Driver Responsibility Program (TDRP), a program consisting of a driving infraction point system coupled with a series of graded fines and annual surcharges for specific traffic violations such as driving while intoxicated (DWI). Approximately half of the revenues generated are earmarked to be disbursed to the state's trauma system to cover uncompensated trauma care costs. This study examined initial program implementation, the impact of trauma system funding, and initial impact on impaired driving knowledge, attitudes and behaviors. A model for targeted media campaigns to improve the program's deterrence effects was developed. ^ Methods. Data from two independent driver survey samples (conducted in 1999 and 2005), department of public safety records, state health department data and a state auditor's report were used to evaluate the program's initial implementation, impact and outcome with respect to drivers' impaired driving knowledge, attitudes and behavior (based on constructs of social cognitive theory) and hospital uncompensated trauma care funding. Survey results were used to develop a regression model of high risk drivers who should be targeted to improve program outcome with respect to deterring impaired driving. ^ Results. Low driver compliance with fee payment (28%) and program implementation problems were associated with lower surcharge revenues in the first two years ($59.5 million versus $525 million predicted). Program revenue distribution to trauma hospitals was associated with a 16% increase in designated trauma centers. Survey data demonstrated that only 28% of drivers are aware of the TDRP and that there has been no initial impact on impaired driving behavior. Logistical regression modeling suggested that target media campaigns highlighting the likelihood of DWI detection by law enforcement and the increased surcharges associated with the TDRP are required to deter impaired driving. ^ Conclusions. Although the TDRP raised nearly $60 million in surcharge revenue for the Texas trauma system over the first two years, this study did not find evidence of a change in impaired driving knowledge, attitudes or behaviors from 1999 to 2005. Further research is required to measure whether the program is associated with decreased alcohol-related traffic fatalities. ^

Uncertainty analysis of cost effectiveness in a tailored intervention to promote screening for colorectal cancer

Background. Screening for colorectal cancer (CRC) is considered cost effective but screening compliance in the US remains low. There have been very few studies on economic analyses of screening promotion strategies for colorectal cancer. The main aim of the current study is to conduct a cost effectiveness analysis (CEA) and examine the uncertainty involved in the results of the CEA of a tailored intervention to promote screening for CRC among patients of a multispeciality clinic in Houston, TX. ^ Methods. The two intervention arms received a PC based tailored program and web based educational information to promote CRC screening. The incremental cost of implementing a tailored PC based program was compared to the website based education and the status quo of no intervention for each unit of effect after 12 months of delivering the intervention. Uncertainty analysis in the point estimates of cost and effect was conducted using nonparametric bootstrapping. ^ Results. The cost of implementing a web based educational intervention was $36.00 per person and the cost of the tailored PC based interactive intervention was $43.00 per person. The additional cost per person screened for the web-based strategy was $2374 and the effect of the tailored intervention was negative. ^

The Open Door Mission: Measuring and predicting outcomes of one community-based substance abuse treatment program

The objectives of this study were to identify and measure the average outcomes of the Open Door Mission's nine-month community-based substance abuse treatment program, identify predictors of successful outcomes, and make recommendations to the Open Door Mission for improving its treatment program.^ The Mission's program is exclusive to adult men who have limited financial resources: most of which were homeless or dependent on parents or other family members for basic living needs. Many, but not all, of these men are either chemically dependent or have a history of substance abuse.^ This study tracked a cohort of the Mission's graduates throughout this one-year study and identified various indicators of success at short-term intervals, which may be predictive of longer-term outcomes. We tracked various levels of 12-step program involvement, as well as other social and spiritual activities, such as church affiliation and recovery support.^ Twenty-four of the 66 subjects, or 36% met the Mission's requirements for success. Specific to this success criteria; Fifty-four, or 82% reported affiliation with a home church; Twenty-six, or 39% reported full-time employment; Sixty-one, or 92% did not report or were not identified as having any post-treatment arrests or incarceration, and; Forty, or 61% reported continuous abstinence from both drugs and alcohol.^ Five research-based hypotheses were developed and tested. The primary analysis tool was the web-based non-parametric dependency modeling tool, B-Course, which revealed some strong associations with certain variables, and helped the researchers generate and test several data-driven hypotheses. Full-time employment is the greatest predictor of abstinence: 95% of those who reported full time employment also reported continuous post-treatment abstinence, while 50% of those working part-time were abstinent and 29% of those with no employment were abstinent. Working with a 12-step sponsor, attending aftercare, and service with others were identified as predictors of abstinence.^ This study demonstrates that associations with abstinence and the ODM success criteria are not simply based on one social or behavioral factor. Rather, these relationships are interdependent, and show that abstinence is achieved and maintained through a combination of several 12-step recovery activities. This study used a simple assessment methodology, which demonstrated strong associations across variables and outcomes, which have practical applicability to the Open Door Mission for improving its treatment program. By leveraging the predictive capability of the various success determination methodologies discussed and developed throughout this study, we can identify accurate outcomes with both validity and reliability. This assessment instrument can also be used as an intervention that, if operationalized to the Mission’s clients during the primary treatment program, may measurably improve the effectiveness and outcomes of the Open Door Mission.^

AN ANALYSIS OF THE RELATIVE INFLUENCE OF RACE, INCOME, EDUCATION, AND FOOD STAMP PROGRAM PARTICIPATION/NONPARTICIPATION ON THE FOOD AND NUTRIENT CONSUMPTION OF A NORTH FLORIDA URBAN CLINIC POPULATION IN CONJUNCTION WITH A SURVEY OF NUTRITION RELATED HABITS AND ATTITUDES

The relative influence of race, income, education, and Food Stamp Program participation/nonparticipation on the food and nutrient intake of 102 fecund women ages 18-45 years in a Florida urban clinic population was assessed using the technique of multiple regression analysis. Study subgroups were defined by race and Food Stamp Program participation status. Education was found to have the greatest influence on food and nutrient intake. Race was the next most influential factor followed in order by Food Stamp Program participation and income. The combined effect of the four independent variables explained no more than 19 percent of the variance for any of the food and nutrient intake variables. This would indicate that a more complex model of influences is needed if variations in food and nutrient intake are to be fully explained.^ A socioeconomic questionnaire was administered to investigate other factors of influence. The influence of the mother, frequency and type of restaurant dining, and perceptions of food intake and weight were found to be factors deserving further study.^ Dietary data were collected using the 24-hour recall and food frequency checklist. Descriptive dietary findings indicated that iron and calcium were nutrients where adequacy was of concern for all study subgroups. White Food Stamp Program participants had the greatest number of mean nutrient intake values falling below the 1980 Recommended Dietary Allowances (RDAs). When Food Stamp Program participants were contrasted to nonparticipants, mean intakes of six nutrients (kilocalories, calcium, iron, vitamin A, thiamin, and riboflavin) were below the 1980 RDA compared to five mean nutrient intakes (kilocalories, calcium, iron, thiamin and riboflavin) for the nonparticipants. Use of the Index of Nutritional Quality (INQ), however, revealed that the quality of the diet of Food Stamp Program participants per 1000 kilocalories was adequate with exception of calcium and iron. Intakes of these nutrients were also not adequate on a 1000 kilocalorie basis for the nonparticipant group. When mean nutrient intakes of the groups were compared using Student's t-test oleicacid intake was the only significant difference found. Being a nonparticipant in the Food Stamp Program was found to be associated with more frequent consumption of cookies, sweet rolls, doughnuts, and honey. The findings of this study contradict the negative image of the Food Stamp Program participant and emphasize the importance of education. ^

Community health workers: The critical link to sustainable, healthy societies in low-resource settings---A model for the Baylor Shoulder to Shoulder Foundation

Community health workers (CHWs) can serve as a bridge between healthcare providers and communities to positively impact social determinants of health and, thus, the overall health of the population. The potential to effect lasting change is particularly significant within resource-poor settings with limited access to formally trained health care providers such as the small, rural village of Santa Ana Intibucá, Honduras and surrounding areas—located on the geographically and politically isolated border of Honduras and El Salvador. The Baylor Shoulder to Shoulder Foundation (BSTS) works in conjunction with Santa Ana's volunteer health committee to bring a health brigade that has provided health care and public health projects to the area at least twice a year since 2001. They have also hired a full-time Honduran physician, a Honduran in-country administrative director, and built a clinic; yet, no community health worker program exists. This CHW program model is the response to a clear need for a CHW program within the area served by BSTS and presents a CHW program model specific to Santa Ana Intibucá and surrounding areas to be implemented by BSTS. Methods used to develop this model include reviewing the literature for recommendations from leading authorities as well as successfully implemented CHW programs in comparable regions. This information was incorporated into existing knowledge and materials currently being used in the area. Using the CHW model proposed here, each brigade, in conjunction with the communities served, can help develop new modules to respond to the specific health priorities of the region at that time, incorporating consistent modes of contact with the local physician and the CHWs to provide refresher courses, training in new topics of interest, and to be reminded of the importance of community health workers' role as the critical link to healthy societies. With cooperation, effort, and support, the brigade can continue to help integrate a sustainable CHW system in which communities may be able to maximize the care they receive while also learning to care for their own health and the future of their communities.^

A review of the Malaria Chemoprophylaxis Compliance Program at ExxonMobil Corporation

ExxonMobil, a Fortune 500 oil and gas corporation, has a global workforce with employees assigned to projects in areas at risk for infectious diseases, particularly malaria. As such, the corporation has put in place a program to protect the health of workers and ensure their safety in malaria endemic zones. This program is called the Malaria Control Program (MCP). One component of this program is the more specific Malaria Chemoprophylaxis Compliance Program (MCCP), in which employees enroll following consent to random drug testing for compliance with the company's chemoprophylaxis requirements. Each year, data is gathered on the number of employees working in these locations and are selected randomly and tested for chemoprophylaxis compliance. The selection strives to test each eligible worker once per year. Test results that come back positive for the chemoprophylaxis drug are considered "detects" and tests that are negative for the drug and therefore show the worker is non-compliant at risk for severe malaria infection are considered "non-detect". ^ The current practice report used aggregate data to calculate statistics on test results to reflect compliance among both employees and contractors in various malaria-endemic areas. This aggregate, non-individualized data has been compiled and reflects the effectiveness and reach of ExxonMobil's Malaria Chemoprophylaxis Compliance Program. In order to assess compliance, information on the number of non-detect test results was compared to the number of tests completed per year. The data shows that over time, non-detect results have declined in both employee and contractor populations, and vary somewhat by location due to size and scope of the MCCP implemented in-country. Although the data indicate a positive trend for the corporation, some recommendations have been made for future implementation of the program.^

Evaluation of CHIP perinatal program outcomes in Harris County, Texas

This study compared initial year trends in prenatal care and birth outcomes of women enrolled in the Texas Children's Health Insurance Program (CHIP) Perinatal program to trends in Medicaid program women. The study utilized claims data from Community Health Choice (CHC), a health plan in Harris County, Texas that provides coverage to both populations. Quarterly data was analyzed and compared for the first two years of the CHIP Perinatal program (2007-2008) to determine if outcome trends for the CHIP program improved over the outcome trends seen with those enrolled in Medicaid. Study findings indicate an increase in the quarterly prenatal care utilization for the CHIP Perinatal population from 2007 to 2008 and the associated birth weights of babies delivered also had marginal improvements during the same timeframe. Enrollees in Medicaid continued to have overall better outcomes than those enrolled within the CHIP Perinatal program. However, the study showed that the rate of improvement in both prenatal care utilization and birth outcomes were greater for the CHIP Perinatal enrollees than those enrolled in Medicaid. ^ The majority of these improvements were significant when comparing each coverage program and from year to year. Lastly, the study showed that there was a correlation between prenatal care utilization and birth outcomes. However, further analysis of the data could not conclusively indicate that access to prenatal care services provided by the CHIP Perinatal program contributed to the increases observed in utilization and birth outcomes for the study's sample population.^

Educación pública universitaria : República Argentina 1998-2008

La educación en la Argentina está articulada bajo criterios sociales establecidos pero que son básicamente arbitrarios y sustentados en supuestos no demostrados que afirman que el conocimiento se construye a partir de ciertos contenidos y no de otros. Dichos criterios no han variado mayormente durante las últimas décadas y siguen utilizándose como plataforma inicial a partir de los cuales se articula la educación posterior del educando. Los sistemas de educación superior en América Latina sufren una crisis a raíz de la creciente internacionalización de las nuevas tecnologías de comunicación e información y de los reclamos de inclusión social de los sectores marginados, entre otras razones. Las tecnologías de compresión digital dan origen a un modelo educativo "en red" caracterizado por un funcionamiento no presencial, mediante el cual se produce la transformación del rol de la Universidad, como centro de descubrimiento y posesión del conocimiento, para convertirse en apenas una intermediaria en la búsqueda del saber y la información. Esta nueva modalidad de educación crece en la medida en que puede cubrir una demanda social de educación superior insatisfecha, conformada básicamente por adultos que trabajan, estudiantes de zonas alejadas de los centros educativos, extranjeros que carecen de opciones educativas y alumnos globalizados. Por ello, la educación virtual nace como una nueva respuesta a viejas demandas. La construcción de una sociedad planetaria y la convivencia del multiculturalismo, además de representar la expresión de sociedades abiertas, que quizás no dispongan de bases comunes de cohesión nacional, debe ser parte de un nuevo proyecto de solidaridad y confraternidad mundial.Resulta sumamente importante que las Universidades de América Latina defiendan su participación como tales en los mercados regionales mediante la adquisición de mayor flexibilidad, actualización y excelencia, para erigirse de esta manera como una opción comparativamente válida. Asimismo, creemos que la educación, entendida como todo el corpus del conocimiento que tiene una persona, no se construye de manera arbitraria sino, por el contrario, de manera selectiva de acuerdo a las posibilidades del educando; y es precisamente sobre la base de esta pormenorizada elección el sustento sobre el cual el alumno llega posteriormente a desarrollos intelectuales superiores. El objetivo del presente trabajo se centra en mostrar la importancia de índole social y política que tienen la flexibilización y la personalización en el currículum de estudios universitarios, al momento de observar el resultado final del ejercicio profesional del graduado. Desde este punto de vista, es fundamental que la elección de los contenidos del plan de estudios de la carrera universitaria estén a cargo del educando, con la dirección de una unidad académica, especialmente en relación con lo que hoy se conoce como "aprendizaje justo a tiempo". Dicho en otras palabras, solamente cuando el educando trasciende ese fundamento institucional e inicial de conocimientos para abrevar en otras fuentes, como las Artes, la Religión, la Filosofía, etc., puede relacionar y comparar conocimientos diferentes entre sí, pero cuya elección obedece fundamentalmente a criterios personales y no meramente institucionales

La diversidad familiar en situaciones de exclusión social. Resultados y reflexiones sobre actividades de investigación, formación y transferencia de conocimientos

El presente artículo se propone caracterizar las configuraciones familiares que habitan en contextos de exclusión social; aportar conceptualizaciones sobre sus modos de funcionamiento a través de la sistematización de los datos recogidos y destacar los efectos formativos que las prácticas interdisciplinarias barriales con esas familias, van produciendo en los psicólogos recién graduados, a través de una tarea de transferencia del enfoque sobre la diversidad tanto en el interior de las investigaciones como a partir de las intervenciones realizadas con las familias en las tareas de incorporados al Programa de Extensión. Asimismo, nos ha interesado poder efectuar una tarea de transferencia del enfoque sobre la diversidad en la formación de los profesionales jóvenes, tanto en el interior de las investigaciones como en el de las intervenciones realizadas con familias en las tareas de extensión. Este trabajo surge de resultados y reflexiones provenientes de tres fuentes: de lo producido en el marco de una Beca de iniciación a la Investigación; de las investigaciones sobre parentalidad, que desde el año 2001 venimos realizando en la Cátedra de Psicología Evolutiva II y del trabajo interdisciplinario con familias asistidas psicológicamente en el interior del Programa de Extensión Universitaria ?Consultorios Jurídicos Gratuitos?, asentados en doce barrios suburbanos de la ciudad de La Plata (convenio entre la Facultad de Ciencias Jurídicas y Sociales y la Facultad de Psicología, U.N.L.P.) A partir de una metodología cualitativa, con participación interdisciplinaria, los resultados obtenidos han permitido por un lado arribar a la caracterización y conceptualizaciones propuestas acerca de las familias incluidas y al mismo tiempo precisar los beneficios que para la formación de estudiantes avanzados y jóvenes graduados trae aparejado el trabajo que articula actividades de investigación y extensión

Educación pública universitaria : República Argentina 1998-2008

La educación en la Argentina está articulada bajo criterios sociales establecidos pero que son básicamente arbitrarios y sustentados en supuestos no demostrados que afirman que el conocimiento se construye a partir de ciertos contenidos y no de otros. Dichos criterios no han variado mayormente durante las últimas décadas y siguen utilizándose como plataforma inicial a partir de los cuales se articula la educación posterior del educando. Los sistemas de educación superior en América Latina sufren una crisis a raíz de la creciente internacionalización de las nuevas tecnologías de comunicación e información y de los reclamos de inclusión social de los sectores marginados, entre otras razones. Las tecnologías de compresión digital dan origen a un modelo educativo "en red" caracterizado por un funcionamiento no presencial, mediante el cual se produce la transformación del rol de la Universidad, como centro de descubrimiento y posesión del conocimiento, para convertirse en apenas una intermediaria en la búsqueda del saber y la información. Esta nueva modalidad de educación crece en la medida en que puede cubrir una demanda social de educación superior insatisfecha, conformada básicamente por adultos que trabajan, estudiantes de zonas alejadas de los centros educativos, extranjeros que carecen de opciones educativas y alumnos globalizados. Por ello, la educación virtual nace como una nueva respuesta a viejas demandas. La construcción de una sociedad planetaria y la convivencia del multiculturalismo, además de representar la expresión de sociedades abiertas, que quizás no dispongan de bases comunes de cohesión nacional, debe ser parte de un nuevo proyecto de solidaridad y confraternidad mundial.Resulta sumamente importante que las Universidades de América Latina defiendan su participación como tales en los mercados regionales mediante la adquisición de mayor flexibilidad, actualización y excelencia, para erigirse de esta manera como una opción comparativamente válida. Asimismo, creemos que la educación, entendida como todo el corpus del conocimiento que tiene una persona, no se construye de manera arbitraria sino, por el contrario, de manera selectiva de acuerdo a las posibilidades del educando; y es precisamente sobre la base de esta pormenorizada elección el sustento sobre el cual el alumno llega posteriormente a desarrollos intelectuales superiores. El objetivo del presente trabajo se centra en mostrar la importancia de índole social y política que tienen la flexibilización y la personalización en el currículum de estudios universitarios, al momento de observar el resultado final del ejercicio profesional del graduado. Desde este punto de vista, es fundamental que la elección de los contenidos del plan de estudios de la carrera universitaria estén a cargo del educando, con la dirección de una unidad académica, especialmente en relación con lo que hoy se conoce como "aprendizaje justo a tiempo". Dicho en otras palabras, solamente cuando el educando trasciende ese fundamento institucional e inicial de conocimientos para abrevar en otras fuentes, como las Artes, la Religión, la Filosofía, etc., puede relacionar y comparar conocimientos diferentes entre sí, pero cuya elección obedece fundamentalmente a criterios personales y no meramente institucionales