Although the community health service system is now established in China, the utilisation of the community health service institutions is low due to the lack of a gate-keeping role of the primary health service providers and referrals among the three-tiered health service institutions. In addition to this, patients who can afford to pay, often seek best services in big hospitals to guarantee the quality of care. Thus, the need of guiding the patients to the community health services and increasing the utilisation of the community health service institutions is becoming an urgent problem, which hinders the future development of community health services. This study focuses on the question of how to increase the utilisation of Chinese community health centres (HCs).A cross-sectional Base-line Survey of Chinese City Community Health Service System Building using the multi-staged cluster sampling was conducted to collect data from all HCs in 28 key contact cities. Relevant indicators of totally 1790 HCs were analysed. The statistical methods included ANONVA and logistic regression.The analysis suggested several key factors for increasing the outpatient workload (OW) at the HCs: establishing an adequate referral system among the different levels of the health system; enhancing the qualification of health personnel and increasing the compensation by the health insurance for services provided at HCs. Other key factors with a positive effect on the OW included: the government ownership of the HCs, the scale of the institutions, the medical equipment used, the mix of health services provided, and the women in childbearing age in the residence. In order to enhance the efficiency in the Chinese health system, a market-oriented reform under the government's planning was introduced in the health sector in 1980s. The two of the main measures adopted by the government to establish a competitive health service market, included the introduction of a competition among the three-tiered health service institutions and the introduction of patients' out-of-pocket payment directly to the health service providers. In this new health service market, there is a price system laid down by the government for services provided by the health service institutions at different levels. The health service institutions can compete with each other to attract patients from the same level or from a different level, while the patients can freely choose the health service providers they prefer most, and pay the chosen provider directly out-of-pocket. Thus, the traditional gate-keeping role of the primary health service institutions is deserted.The health service institutions compete for patients to be able to generate the revenue that they require. The competition stimulates the health service institutions to update their facilities and equipment, enlarge their scale, enrol excellent physicians by offering liberal wages and benefits, and adopt a positive attitude towards patients' preferences. Thus, there is no waiting list and the efficiency of health reform is overall achieved. But simultaneously, there is a concentration of superior health resources and patients at the third-tiered health service institutions as well as a decline in the use of primary and secondary health service institutions. This results in a serious equity problem, especially with regard to patients without high income, who cannot afford to pay directly to physicians. Therefore, the Chinese government endeavoured to develop a convenient and affordable primary health services - community health service - for the city residents. This mainly involved a transformation of the former health service institutions at the primary level and some health service institutions at the secondary level at the end of 1990s , 2010, 30(2):141-144; "Analysis of medical insurance reimbursement rates of community health stations sponsored by various entities". Chinese Journal of Hospital Administration, 2010, 26(3):205-208, and "The Survey Analysis of the Health insurance Compensation Impact on the Income of City Community Health Center in 28 Chinese Cities", Chinese Health Economics, 2010,29(4):47-49. etc.JX , lecturer, PhD student at the Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology. Specialty is Health Service Research, and research on Chinese community health care management and policy. The latest published papers include " The Former Yugoslav Republic of Macedonia Health System Reform Summarization", Chinese Journal of Maternal and Child Care, 2010, 25(8):1022-1023 and 25(9):1169-1170; "The Ukraine Health System Reform Summarization in Chinese Journal of Social Medicine in 2009, 26 ( 2 ):82-84; The influence of supporting life environments on the psychological health of the rural five-guarantee aged farmers in Chinese Public Health Care in 2006, etc.WW , lecturer at the Jiangsu University, PhD student at the Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College of Huazhong University of Science and Technology and researches in Health Service and Management. The latest published papers include " The study of outpatient health staff allocation efficiency of Shenzhen Maternal and Child Care Hopital" and "The study of inpatient health staff allocation efficiency of Shenzhen City Maternal and Child Care Hospital " in Chinese Journal of Social Medicine, 2008, 25(2): 80-82. and "The Development, Effect and Concerned Issues of Pilot Work of National Community Health Service System Building in Key Contact Cities--Based on the Comprehensive Analysis of the Baseline Survey and Routine Monitoring Data" in Chinese Journal of Social Medicine, 2009,26 (6):321-325.YL  , PhD student at the Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College of Huazhong University of Science and Technology. Specialty is Health Service Research, and research in Chinese community health service management and policy. The latest published papers include "Slovakia Health System Reform Summarization" in Journal of Science Discipline Research; "The frequency distribution analysis of order rank of scientific paper of first-rate world biomedical scientists--study case of Nobel prize winner of physiology or Medicine" in Journal of Science and Technology Philosophical Research in 2009.JZ , PhD student at the Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology. Specialty is Health Service Research, and research in Chinese community health service management and policy. "Progress of medical insurance in community health facilities of the key contact cities" in Journal of Chinese Health Policy in 2010, "The comparison analysis of evaluation methods of scientific paper--study case of first-rate world biomedical scientists" in MP , Assistant professor  at the Department of Health Organisation, Policy and Economics, Faculty of Health, Medicine and Life Sciences, CAPHRI, Maastricht University Medical Center, Maastricht University, The Netherlands. Research areas: health care funding and management, out-of-pocket payments, stated preference methods in policy evaluation. Numerous publications in these research areas.HL , MD, the doctor at Wuhan City Maternal and Child Health Care Centre. He has participated in 8 projects, such as "The study on the children's physical growth under 7 in the ten provinces in the rural China", "The study on the baby anaemia in three counties of Hainan Province", etc., and accumulated rich experience in the data collection and data analysis, and published some papers on the maternal and child health in the Chinese journals, such as Chinese Child Health Care, Chinese Maternal and Child Health Care, and Behaviour Medicine, etc.PY , PhD, assistant professor, the deputy director of Department of Epidemiology and Health Statistics, School of Public Health, Tongji Medical College, Huazhong University of Science & Technology; the research on biological statistical analysis and its application, and the evaluation of population health promotion performance. He has conducted more than 7 national and provincial projects and published 12 medical college textbooks and more than 20 papers in his field.ZL (1959.9), Professor, PhD supervisor and the director of the Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, the famous national health expert and research on Chinese city community health service management and policy for more than two decades. He has published more than 78 papers on community health service research, and conducted 16 projects from the National Natural Science Foundation, Ministry of Health and Hubei Provinces, and wrote 7 books on health service.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/10/151/prepub


An author name was incorrectly spelled as Jun Lou. The correct spelling is Jun Luo. The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.In the published article, there was an error in affiliation 1. Instead of, the Department of Cardiology, Affiliated Ganzhou City Hospital, Nanchang University, it should be, the Department of Cardiology, The Affiliated Ganzhou Hospital of Nanchang University.In addition, there was an error in the affiliation(s) for Ming-Sheng Zhou. Instead of, 2 Department of Physiology, Shenyang Medical University, Shenyang, China, 3 Department of Physiology, Jinzhou Medical University, Jinzhou, China, they should only have, 2 Department of Physiology, Shenyang Medical University, Shenyang, China. The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Writing and editorial assistance was provided by Johna-than Maher, PhD, of BlueSpark Healthcare Communications, and was contracted by Boehringer-Ingelheim Pharmaceuticals, Inc. Dr. Govindan meets the criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICMJE), was fully responsible for all content and editorial decisions, and was involved in all stages of manuscript development. Dr. Govindan received no compensation related to the development of this article.Ramaswamy Govindan has served as a paid consultant or been on the Advisory Board of AstraZeneca; Avantis Medical Systems, Inc.; Bristol-Myers Squibb Company, Boehringer Ingelheim GmbH; and Eli Lilly and Company, and is a member of the Speaker’s Bureau of Eli Lilly and Company and Genentech, Inc.


The ability to control balance during activities of daily living (ADL) is impaired in older adults as a result of deterioration in the sensory systems , the cognitive system , and the musculoskeletal system. Consequently, many older adults face a risk of falling during their ADL. In most cases, falls and related injuries impair the quality of life and result in physical limitations, anxiety, loss of confidence, and fear of falling. Among a variety of fall prevention interventions, adapted physical activity programs have been suggested for improving balance control during ADL. These programs challenge the sensory, cognitive, and musculoskeletal systems while addressing balance constraints such as orientation in space, changes in direction, and the speed or height of the center of mass during static and dynamic situations resembling ADL. The above-mentioned elements can be dealt with through a combination of balance and coordination exercises that challenge the postural control systems in multiple dimensions—including vertical and horizontal changes of the center of mass, standing on unstable surfaces with a reduced base of support, and changing body directions. Consequently, such exercises require environmental information-processing. The combination of dual-task, function-oriented challenges while controlling balance stimulates the sensory and neuromuscular control mechanisms. Among older adults, these programs have been found to improve static and dynamic stability, as well as a number of aspects in the quality of life. Recently, they have also been found to improve cognitive functions such as memory and spatial cognition. Aging is subjected to longitudinal processes as a consequence of physiological changes, such as a higher level of stress, mitochondrial dysfunction, abnormality of inflammatory processes, decreased hormone production, and decreased metabolic rate which can lead to catabolism and degeneration of organs  to present studies examining the effect of performing balance and coordination exercises on various aspects of the quality of life of older people; and (b) to present suggestions for practical applications.The author performed a literature review of available studies on the research topic dealing with different effects of balance and/or coordination exercise programs on various aspects of older adults’ lives. Research studies were selected on the basis of research topics that included the following keywords: balance exercise, coordination exercise, postural control, risk of falling, frailty, and quality of life, found in the world’s acknowledged databases: PubMed, EBSCO , Google Scholar, and Science Direct. The search was not limited by any period of time. From the database/journal searches, 2,333 titles/abstracts were retrieved. The majority of the studies were detected in the Google Scholar database. The titles and abstracts of some identified articles were then checked for relevance. Subsequently, the search was performed again, focusing on the occurrence of at least one keyword in the title or abstract of articles written in English and representing scientific study, thereby significantly narrowing down the selection. Altogether, 326 studies were found. After removing duplicates and titles/abstracts unrelated to the research topic, 25 studies were found to be relevant to the research topic , significantly improved cognitive function  of older adults  while the body is constantly shifting from foot to foot, with the knees and hips held in flexion . During each movement, different parts of the body take turns playing the role of stabilizer and mover, allowing smooth movements to be executed without compromising balance and stability. Older adults who performed this form of exercise were found to have significantly better postural control and stability in conditions with simultaneous disturbance of vision and proprioception, compared to active nonpractitioners . When planning each training session, it is important to keep in mind the participants’ adaptation process to the exercises and to determine the session’s optimum duration, allowing for gradual and safe exposure to new equipment or a new exercise.AD performed the drafting, analyses, and final version of the entire manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The Reflective and Critical Thinking was found as a subject, subject content and didactic strategies. Of the 562 subjects reviewed, this type of thinking is found in 46% of the humanities area and 42% in the area of research and professional discipline. It is important to train teachers to achieve coherence between the pedagogical model approach, teaching strategies and evaluations.nursing programs in the Andean region contemplate the critical thinking as cognitive and personals skills of communication. They also use real situations analysis, supervised practice, simulation labs and specifically learning based in problems to develop the capacity to solve them, decision-making and develop communication skills, including analysis, synthesis and evaluation. Moreover, the nursing profession is evolving, so that it is increasingly moving away from the biomedical model of care, focused on the instrumental, to focus on people’s health care, with primacy of dialogue and agreements between the professional and the person under care. As part of a multiprofessional team, this requires changes in the curricular proposal and, in turn, a qualifying teacher for a new profile of graduate, whereby reflection, self-criticism and professional responsibility are developed.Therefore, it is necessary to work intensely to reduce the dichotomies that are present in nursing programs, namely: between theory-practice; training and the reality of professional practice; and the student as a passive part of the teaching-learning process and the professional who is required, active, proactive, creative, analytical, with contextual perspective, flexible, with logical thinking, able to carry out a permanent and continuous search for information, able to contribute with his profession to the solution of health problems..The General Conference of the United Nations Educational, Scientific and Cultural Organization (UNESCO), at its 38th session, held in Paris from 3 to 18 November 2015, “Recommendation about Adult Learning and Education” states in one of its objectives the need to develop people’s capacity to think critically and to act with autonomy and a sense of responsibility(-) and the clinical judgment is the result of this process. The development of the clinical judgment  is one of the most important and challenging tasks of being a nurse. Clinical reasoning precedes clinical judgment and the decision-making that is important in professional and personal life.Critical thinking (CT) is a process and a learning outcome -4 and.In order to achieve professionals with reflective and critical thinking (RACT), it is necessary to make deep changes in the educational dynamics, in the teaching and student roles, in the use of pedagogy and didactics to transmit knowledge, the curricular structure, the strategies of teaching-learning. These changes are expected to be centered on the student, who must actively participate in the learning process in order to achieve greater development of his or her capacities for reasoning, self-learning, self-evaluation, self-management and self-regulation. Likewise, it is expected that teachers to be critical and creative, attending to individual ways of learning, encouraging the development of good thinking in the student.. The world changes fast and new realities arise, so there is a fundamental need of people to develop capabilities that allow them to respond and adapt themselves to these changes.Literature points out that critical thinking is the “essential foundation for education, since it is the basis for adaptation to the individual, social and professional demands of daily life in the 21st century and beyond”. The wo.Critical thinking is “the process of seeking, obtaining, evaluating, analyzing, synthesizing and conceptualizing information as a guide, to develop self-conscious thinking and the ability to use this information by adding creativity and taking risks”. and, since the end of 1980, various strategies for its teaching have been discussed at all school levels. On the other hand, authors point out the importance of generating opportunities to develop RACT in students. Therefore, some authors emphasize the importance of developing it in all health situations in favor of the patient. The nursing professional developing RACT will know where, when and how to use their knowledge, skills, values and attitudes.Authors pointed out one of the first definitions of critical thinking: “knowledge, skills and attitudes” and, sil levels. On the patient,6-7.The motivation for nurse training in the Andean region became evident in the 1960s. In particular, Colombia generated the first degree program in 1958, which was approved in 1961. In the same period, Venezuela, Ecuador, and Peru initiated undergraduate programs; in the case of Bolivia, it happened only until 1970Sistema de Aseguramiento de la Calidad de la Educación Superior) was implemented, as well as the Accreditation of the programs and the own regulations or nursing law emerged in each country of the region.The 1980s were marked by the rise of postgraduate programs, increased development of research and the generation of knowledge. The 1990s saw a boom in graduate, specialization, masters, and doctoral programs, the latter especially in education. However, there were also more options for the qualification of nursing professionals for the teaching role. On the other hand, the Higher Education Quality Assurance System  shows the need to expand the research in the area of education, to achieve greater development of research and to work in education and nursing policies and practices. On the other hand, the latter shows the need to implement and evaluate pedagogical and didactic strategies that help the student to develop a critical judgment, justified decision making, comprehensive memory and communicative competence.The literature-11 shRed Iberoamericana de Investigación en Educación en Enfermería - RIIEE), in 2011, identified as a research priority, “The development of RACT in nursing students”, within the tree of the problems detected in its research line Higher Education and Nursing. For the development of this research purpose, the Network suggested a multicenter macroproject with the theme “Strategies to develop the RACT in nursing students: situation in Latin America”. In fact, the conceptual paradigm refers to “critical theory and constructivism, since RACT is an analytical, cyclical, broad and systematic process, but not rigid; its analysis and interpretation allows to have elements for decision-making, as well as to make informed choices”(-).For its part, the Ibero-American Network for Research in Nursing Education , Brazil, the Southern Cone, Europe, and Mexico and the Caribbean. The investigation is planned in three stages: 1. Diagnose; 2. Planning and implementation of interventions; and 3. Evaluation. The diagnostic stage includes: 1. The state of the art on scientific production in RACT and teaching strategies for its development; 2. Characterization of educational strategies for teaching the RACT collected in nursing literature; 3. To determine the development of the RACT competence in the different nursing curriculum; 4. To identify the educational strategies used by teachers to develop the competence of reflective critical thinking in nursing students; 5. To identify levels of critical thinking in nursing students according to the classification of Paul and Elder (unreflective thinker - master thinker). Objectives 4 and 5 are currently being developed..The analysis of the “Scientific Production in RACT in Nursing in 1990-2012 in Ibero-America” produced among others the following conclusion: the formation of a critical reader and the investigative process are strategies that help university students to be critical and autonomous and to access more critically to the knowledge of the disciplinary area. For this, teachers are required to make of each moment and situation in the teaching-learning relationship an open forum for reflection, debate, questioning and contrasting of the different perspectives around the area of professional training and society’s problems.After reviewing the literature on the web of science by using the descriptors critical thinking and nursing, education and curriculum, it was not possible to find studies that analyzed the presence of RACT in the curriculum of nursing degree programs. However, it is very striking the motivation to analyze the importance of its development and studies that demonstrate its value, as well as the use of different and combined teaching-learning strategies to achieve the formation of RACT in nursing students.This study was done with the purpose of to evaluate the teaching of transversal competence of the Reflective and Critical Thinking that is fundamental in the decision-making and solution of nursing problems, in degree programs of public and private institutions in the Andean region.Asociación Latinoamericana de Escuelas y Facultades de Enfermería - ALADEFE).The coordinating group of RIIEE developed the research project from which the research groups of each country and region of the Network were made up, integrated by members of the Network and researchers in education and nursing, who are also teachers in Higher Education Institutions (HEI), and mostly with PhD academic level. The HEI in Nursing (HEIN) were identified through the Ministries of Education, the Associations of Schools and Universities of Nursing of each country and the Latin American Association of Schools and Universities of Nursing  and the current ethics legislation in each country, was approved by the Ethics Committee of the University of Antioquia, Colombia, by Act No. CEI-FE 2015-25 on July 31, 2015. The respect for privacy and confidentiality were ensured to each Program Director, with the informed consent signed by each participant. The project was also sent to them and their understanding was guaranteed. In turn, we conceded the right to choose what information they wanted to share. Confidentiality was maintained by institutional coding. Finally, was given a deadline of 15 days to obtain the response of acceptance to participate.The target population of this research were 187 undergraduate nursing programs in the Andean region: Bolivia (47), Colombia (47), Ecuador (21), Peru (62) and Venezuela (10). We considered only the nursing curriculum of the HEI, recognized by the Associations of Schools and Colleges of Nursing of each country or its counterpart, regardless of whether they were public or private. Resulting in the nursing curriculum of 76 Institutions that correspond to the 40.64% HEIN that teach undergraduate nursing in the Andean region: Bolivia (7), Colombia (38), Ecuador (11), Peru (14), and Venezuela (6). Due to the difficulty in obtaining the information, we checked web pages, contacted HEIN members, made contacts by telephone, in some cases, we made personal visits and, finally, the complete program was requested in PDF format for the complete the instrument of the research group. In addition, the HEIN did not refused to participate, but some institutions did not respond to the invitation. The result of this process: 30 institutions accepted to participate and provided the complete information, and out of 46 partial results were obtained. An HEIN database of the names, telephone numbers and e-mail addresses of the authorities in charge of managing the programs was created in order to follow up on their responses.(-).After identifying, during 2011 and 2012, the theoretical and conceptual framework of RACT from different authors and different perspectives , despite the abundance of literature about the subject, we concluded that the concept is very unclear from a nursing point of view-14.However, it was necessary to establish a concept that was accepted by the research group of the Network, that allowed to determine a starting point or consensus to carry out this work and, without detriment to seek some level of fidelity to the multiple approaches of the scholars of this research object, that was understandable for the group and reflected what was intended to be done in its research phases and stages. and Paul; Elder, the elements of the CT and the attitudes of the Critical Thinker proposed by these authors. With the material analyzed, RIIEE constructed the following concept: “Reflective and critical thinking is a complex, systematic and deliberate process of reasoning, self-directed and action-oriented. It is primary purpose to choose, based on intellectual and affective processes , the best response options that favor the solution of nursing problems, in well-defined contexts and in accordance with the ethical postulates of the profession that allow it to act with rationality and professional autonomy”.The Network took as a theoretical framework the approaches made by Paul and Paul; Elder, the elutonomy”.The research process included the conceptual and theoretical analysis of the curriculum, the updating of the context of research development in nursing education in each country of the region, the characterization of the HEIN and, finally, the results of the state of the art on teaching strategies for the development of the RACT 1990-2012, Andean region., the curriculum as a macro concept that encompasses the socializing function of the school is at the same time pedagogical ideas, structure of contents in a particular form, precision of them, reflection of educational aspirations more difficult to translate in concrete terms and skills to promote in the students. In Posner, who raised the great number of phenomena involved in the curriculum; Gimeno-Sacristán; Pérez-Gómez, there is five categories in which the definitions of curriculum can be articulated: as an organized knowledge structure, production technology system, instructional plan, set of learning experiences and problems solution.Once the exhaustive bibliographic review was carried out, the instrument was designed based on the concept of Stenhouse, the custudents. In Posn Posner, who raez-Gómez, there Based on the aforementioned, the specific instrument for this investigation was constructed with three parts. The first with 10 items, with general information from the HEI or University. Each University is subdivided into Centers that are parted into Colleges and these are divided into programs: name, geographic location, type of institution, accreditation data, mission, vision, objectives, curricular guidelines for degree programs, web page, and data about who completed the instrument. The second, 28 items, for the College, School, Department or Nursing Program (typology to identify HEIN in the region), with the following subsections: general aspects of the nursing program, character within the institution, number of sites where the program is offered, accreditation data , program justification, mission, vision and objectives of the program, evaluation process, graduation profile, pedagogical model, number of hours and credits, curricular structure (nursing program subjects that correspond to each area or component). Finally, the general characteristics of the teachers: kind of affiliation with the institution, time worked, and maximum educational level achieved. The third, 9 items, for specific information about each of the subjects: name, component or area to which it belongs, number of hours and credits, type of subject , contents, teaching-learning methodologies and evaluation process.The members of the research group carried out an analysis of the validity of the content of the instrument. Afterwards, the pilot test was conducted, starting with its implementation in each of the HEI in which the researchers worked; the results were analyzed and the corresponding adjustments were made in its structure. Subsequently, the adjusted instrument was tested with five members from the region, one from each country, but different from the research group. Because of this test, we decided to design a guide to facilitate the completion of the instrument and ensure objectivity in the collection of information, because of the language differences. It is possible to obtain the final version of the instrument from the authors of the project.Each participant received the letter of invitation, the project, the informed consent, the instrument to collect the information and the corresponding guide for its completion in hands and by e-mail.The information obtained was reviewed and, in some cases, it was necessary to request the complementation of some aspects of the instrument. Then we proceeded to codify the HEI or Universities and the HEIN. The information was included in Excel tables designed with the predetermined categories and subcategories, which were later incorporated into the SPSS statistical analysis program, version 19. The information was processed using descriptive statistics, with frequency distributions and average analysis, and analyzed by institution, by country and as an Andean region, according to the categories and subcategories determined, allowing comparisons between countries and conclusions to be drawn as a region.The analysis of the information was carried out using the deductive-inductive method, considering the objectives of the project and the revised conceptual theoretical framework, with the aim of determining the presence of the RACT, explicit and implicit, in each categories, the coherence of the approaches between University-College-Program, the coherence between the objectives, contents, teaching-learning strategies and the evaluation process in each subject. In this sense, we analyzed the linearity or coherence with respect to what was proposed, developed and evaluated in relation to the RACT and, finally, the contradictions and inconsistencies found in the aforementioned approaches were pointed out. We considered national and international studies about the subject for the analysis and discussion of the results obtained, in addition to the documents mentioned above.According to the information obtained by the research group, the Andean region has 2,552 HEI; 410 with character of universities and 160 are public, 220 are private and 14 are in special regime. There are 167 universities with nursing programs, 146 affiliated and recognized by the respective Associations of Schools and Colleges of Nursing in each country. The number of accredited nursing programs in the Andean region is 43: Colombia (20), Peru (20) and Bolivia (3). Precisely, of the 20 accredited institutions in Colombia, 11 already have their certifications renewed, which are of 8, 6 and 4 years; 5 and 6 years for Ecuador and 3 years for Peru. Bolivia is just beginning the process and Venezuela has no information about it.The total population of HEIN by country was Bolivia 47, Colombia 42, Ecuador 21, Peru 62 and Venezuela 10. A total of 76 HEIN answered: Bolivia 7; Colombia 38; Ecuador 11; Peru 14 and Venezuela, 6. These institutions constituted the sample of the study.Twenty-one of these institutions are certified: in Colombia 20 and in Bolivia 1; 12 did not include this information and 41 were not yet certificated. Of the total number of institutions that provided the information, 47 are public, 26 private and three do not know the information. Administratively, 36 are programs; 22 Colleges; 21 Schools and one Department.The number of hours and credits of the programs showed considerable heterogeneity: the average number of hours was 5,552.3, corresponding on average to 232.11 credits. Regarding the number of hours per credit, the lowest is in Peru, which has 13 hours per credit, and the highest is in Colombia, with 48 hours corresponding to one credit. There are institutions that do not work with credits, especially in Bolivia; others did not included this information, among them Ecuador and Venezuela.The main characteristics of the 912 teachers developing nursing programs in the Andean region are: 501 (54.9%) with a Specialist degree; 634 (69.51%) with a Master’s degree and 58 (6.35%) with a PhD; 249 (27.3%) with a postgraduate degree in Education. and .From a general perspective, it should be noted that of the five countries in the region only Venezuela and Peru explicitly present the RACT in their Organic Law (OL) or Higher Education Law in terms of integral and permanent formation of reflective critical citizens in Peru).The results of RACT’s presence are presented below: Universities or HEI; in Colleges, Programs, Schools and Departments, that is, in HEIN; and in the subjects.receptor and analytical constructor, with critical conscience; as methodology to achieve it, in Colombia and Peru: “promoting reasoning, the CT and creative”; as a result of learning in Ecuador and Venezuela: capable of solving problems, CT promoter.When analyzing the information of the Universities or HEI, we found the RACT as direct mention, indirect mention and evidence of traditional positions was found. Directly, it was found as a training purpose in Bolivia, Colombia and Peru: integral formation, relation practical theory; and as objective in Colombia: future graduates with ethical conscience, autonomy, democratic spirit and highly qualified.The indirect mention was found as result in the five countries of the Region, as a strategy in Bolivia, Ecuador, Peru and Venezuela: teaching, evaluation as a final product, training in instrumental action, the educational process as providing knowledge.There are still traditional postures: prepare professionals and leaders with CT and social conscience. The second, as a methodological strategy to achieve its development: to develop and implement pedagogical methods that encourage reasoning, CT and creativity, and that encourage habits of discipline and productive work. And the third, as a result of the formation process that includes the subject: Training of critical, self-managed, creative and proactive men and women; and, moreover, refers to the projection and utility: with the promotion of CT and the generation of knowledge, thanks to the strengthening of critical analysis, anticipation and vision of the future and development of viable alternatives to the problems.By going a little deeper into the HEI, we found that 88% (38) consider the RACT: 63% (27) in the mission; 7% (3) in the vision; 51% (22) in the objectives and 30% (13) in the curricular guidelines. Among these, three defining categories were identified. The first, as a training purpose: At HEIN, RACT is expressed in the graduation profile, objectives, curricular guidelines and mission. the training of professionals with scientific, technical, critical, analytical and reflective knowledge, as well as communication, oral and written expression skills; and referred to a critical, creative, participative, supportive, innovative and sensitive attitude towards social change.In a cross-sectional view of what is proposed by curricular programs, three categories were identified to be highlighted. The first, the development of cognitive and personal skills, expressed as promote and develop research, generating knowledge in the different areas of nursing that contribute to universal science and the solution of health problems; and the use of technologies: learns permanently developing the capacity of abstraction, analysis, synthesis and using information technologies. The third, its finality, related to the ability of individuals, families and community groups to interfere and make decisions in the solution of health problems, to provide comprehensive care with the capacity to solve health problems in changing and emerging environments.The second, the way in which its development could be achieved, among which the research stands out: social-critical-constructivist and second, the cognitive - humanistic in four (4). Other models or approaches were also identified, among them: dialectic, technological, psychological, the problematic schools, the Active, Reflective, Dialectic, Innovative and Critical. Finally one institution works with the model based on the pillars of education, in which learning to know, learning to do, learning to be and learning to live together, which includes, educating for life, educating for life, educating for work, educating in society and for society.Concerning the pedagogical models expressed in the HEIN, a variety was found in the denomination. First of all, the constructivist approaches are highlighted in eight (8) Institutions, with some connotations as the model  society.The RACT in the subjects of the programs of Nursing in the Andean regionOnly 29 of the 76 HEIN participants in the study were able to obtain information on subjects (38.15%), and 22 (75.86%) of these in nursing programs, RACT was present in different elements of the subjects. 562 subjects were reviewed, 159 (29%) of which have no information about teaching strategies or evaluation. Moreover, some programs record the same teaching and assessment strategies for all subjects in the program, 45 (8%).Workshop of Critical Thinking and Introduction to CT; second, as a subject content: CT in Nursing, and, third, RACT is evidenced in teaching-learning strategies.The information provided makes it possible to indicate RACT as a subject: The highest percentage of subjects in which RACT is evident correspond to the area of humanities, with 46% (55), in which analysis of real situations, group work, concept maps, role playing and seminars are predominant.In second place, it is in the professional-disciplinary area with 42% (307) subjects with the predominance of the following strategies: supervised clinical practice, clinical case, problem-based learning, simulation laboratories, and the nursing process. The research is in the same place, 42% (41) subjects. The most commonly used strategies are: critical discussions of research reports and articles, project development, workshops, and problem-based learning.In the last place, subjects from the basic or foundation area 144 (24%). Including discussion workshops, concept maps and case studies.presentation and discussion of clinical case, group work, clinical practice, flipchart, observation guides, debates, discussion about specific topics, resolution of case studies, support of the nursing care plan, investigative reports , workshop development.A great variety of strategies have been identified, among them are: the development of competencies, the acquisition of skills, the development of superior cognitive processes, the professional spirit and the development of processes and independence.What is evaluated: the capacity for criticism, analysis and synthesis, evidence of problem solving, case analysis and Nursing Based in Evidences, didactic relationship analysis and fundamental elements of the RACT, conceptual knowledge, written and oral reflections, group work, practical reflections and group discussions.Finally, in some of the subjects, the intentionality of the evaluation of the RACT is explicitly presented: written works about the topics of each seminar in which the proper handling of the bibliography is evidenced, It is evident that traditional evaluation techniques still exist: evaluating procedural aspects, dexterity, motivation and initiative in the procedures, memory evaluation, participation in class, oral and written interventions and, finally, the replication of the topics studied in classes.Therefore, the analyzed programs show interest in including as an important element in their future graduates the development of the RACT. This aspect is vanishing in the development of the subjects. It is evident in the pedagogical strategies, but it is lost until disappearing in most of the evaluative processes.The analysis results of the plans and programs of the HEI and HEIN allow to conclude that the proposes of the Law of Higher Education to develop the RACT in the students does not guarantee that it is included in the subjects and evaluations..What is stated in HEI and HEIN allows us to infer that epistemological and theoretical contradictions are present in the Institutions and among them. It makes necessary an epistemological, theoretical and methodological consideration in order to achieve alignment and coherence between the purposes in the curricular guidelines and what is programmed in the curricular plans for the concrete work with the students. This matter goes against comprehensive training, since it is demonstrated that critical and reflective skills contribute to train professionals with greater ability to care for patients.It should be noted that it is the University or HEI that determines the philosophical bases that will guide the academic units that compose it, so that they, in turn, incorporate these principles into their academic programs. The results show that there is no linearity between the proposals of the university with respect to its mission, vision, objectives, graduation profile, curricular guidelines, and what is proposed in the nursing degree programs. There is more linearity in Institutions with a longer trajectory and development, private and public ones.. The subjects in the professional area use strategies such as case study, supervised clinical practice and other relatively new ones as problem-based learning and simulation laboratories. Strategies that, by involving simulation or potential practical actions, contribute to enhance critical skills and make decisions that lead to the future professional committing fewer errors during the care of patients(-).The analysis of the areas in which the subjects are grouped made it possible to identify that the subjects of the humanities area have the highest percentage of presence of the RACT. This result can be explained by the strategies used, but even more by the subjects under study, since it has been demonstrated that the teaching-learning strategies based on the humanities have a significant impact on the development of skills such as clinical reasoning. The supatients-26.By contrast, it is not the same with the subjects of the foundation or basic area in which it is necessary to return to some knowledge aspects that already exists, such as anatomy, physiology, anthropology, psychology, statistics, among many others. For some students these topics are very difficult and involve, on several occasions, an excellent dose of memory. However, the teaching strategies that develop the RACT are not so frequent. It is important doing more research on this point to sustain if it is true.On the other hand, for the majority of HEIN, training is conceived as qualification and progress achieved by people and as a principle of theories, concepts, methods, models, strategies and courses of pedagogical action that aim to understand and qualify the teaching. In some cases, the transfer of knowledge is approached, but it still underlies the concept of learning as acquisition of knowledge built and finished; the teacher is the one who has the knowledge and the student is who learns what teacher knows.. It includes as proposals the development of social skills, with emphasis on oral and written communication, cognitive skills including problem solving, establish different alternatives, understand the consequences of actions, make decisions and critical thinking. Also, intend to achieve in the student some characteristics of the critical thinker like to be creative, innovative, proactive, analytical, participatory, entrepreneurial, self-critical, supportive, humanistic, ethical and scientific.The curricula of the Andean region include explicit elements that contribute to the development of the RACT, such as reading, writing and reasoning, allowing to the future professional to know how to learn, reason, think creatively, generate and evaluate ideas, make decisions and solve problems. It incthinking. Also, ientific.Regarding the pedagogical models proposed by the HEIN, inconsistencies between the approach of constructivist approach and meaningful learning are evident. The axis is the student and the repetitive approach in the subjects with master class methodology, reading guides and analysis made by teacher, but not by the student. It shows a traditional model centered on the teacher, with an emphasis on memory, comprehension and the application of concepts. Some subjects focus learning on the acquisition of concepts, despite using the integrating project as a teaching-learning strategy, workshops and practice as evaluation. The pretense for the development of the RACT is not in line with the evaluation, with the examination, in the application of contents, since it is centralized in aspects of memory and knowledge, in an asymmetric theory-practice relationship., it is not really concrete how it could be achieved. Strategies such as simple repetition and teaching for the acquisition of concepts show the persistence of the traditional educational models.Although significant learning is intended and the importance of integrating it into the formation of learning approaches with the intention of promoting critical thinking, added with successful learning experiences, it is This study found there is no a clear structure to operationalize the theories of the proposed pedagogical models, even though there are expressions that point to RACT. Thus, the elements important for its development are presented in the teaching and learning strategies in a more remarkable way., from the positivist, rationalist or empirical analyst paradigm, to the humanist and critical curriculum to the socio-critical paradigm and critical thinking based on hermeneutic processes. The social and contextual  aspects that influence and determine the health behaviors of the people are still incipient in the curricula.The curricular guidelines express the intention to transcend technical rationality and behavioral objectives, from trriculum to the rocesses. The sourricula..According to what has been demonstrated, it is possible to state that there is no predominance of a pedagogical model, but a mixture of several models in the same program with varied influences. The presence of the following models was identified: Traditional Pedagogical, Behavioral, Cognitive, and Social Pedagogical, the latter being very tenuous.. Considering these elements, we can assure that the creation of opportunities is present with more intensity in some curricula, and self-evaluation and hetero-evaluation have begun to be implemented especially in public institutions.There are four fundamental elements to forming critical thinkers: first, the question; second, the creation of continuous opportunities to participate in dialogue, debate, research, and critique; third, self-evaluation and hetero-evaluation; and fourth, teachers as models of critical thinkers. Consid.Mentioning the subjects, it is not evident that the thought is motivated by complex kind of questions that encourage exploration, generate evaluation, create concepts and knowledge.. Other authors suggest, for the reports, questions about the purpose, information, concepts, assumptions, implications, points of view and the questions, as elements that favor analysis, the evaluation of ideas and reasoning.The literature points out that the Socratic questions stimulate the student to use existing knowledge, since they promote a greater understanding and integration of new knowledge, they foment the habit of thinking critically,34. Oeasoning,35., problem-based learning, supervised clinical practice, the nursing process and simulation laboratories. In this article, we only refer to two of these strategies, which were selected because of the great advance of information and communications technologies. The growing need to access this kind of infrastructure as a fundamental part in the training of future professionals and as an example of a single teaching and learning strategy is not sufficient to achieve the RACT, rather, the use of different techniques enhance its development, as we will see below.Like other researches, this study found that the most used strategies in the progress of the professional area that promote the development of RACT are the case study,36, plearning, supervpractice, the nu process,38 antories,-38. I.We agree with the conclusion of authors who suggest that Problem-Based Learning and simulation labs are active strategies that develop RACT in nursing students.(-), in addition, it allows to integrate knowledge, to think as a professional, to analyze individual situations in specific contexts from different angles, to use theoretical concepts in the delimitation of a concrete problem. It also stimulates collaborative and team work, the work with different points of view. The question-problem is the motivator in the search for alternative solutions, is useful in simple and complex situations, allows to apply theory in practice, promotes the exchange of ideas, teaches students to learn to control their own thinking and promote the exchange of ideas and intellect. In addition, it helps to incorporate time management and take responsibility. It also facilitates the integration of the four elements of the Nursing metaparadigm: the person receiving the care, health as purpose, the nature of the nursing and the context or environment.The case study, moreover, promotes active learning, helps to solve clinical problems, promotes the development of critical thinking skills-35, i problem. It alsntellect. In addThe case study allows the simultaneous implementation of other strategies that further enhance the development of RACT, such as concept maps, the analysis and selection of scientific evidence, the nursing process, nursing history, role-playing, argued discussion and debate.In contradiction to all the positive aspects of the case study in the development of RACT, the dichotomy between theory and practice in a large number of the curricula reviewed is an obstacle to achieving all the benefits pointed out. Since some teachers are in charge of the development of the theoretical subject in the classroom, others are in charge of their practical part in other spaces that require this care. shows how the promotion of RACT is relevant. In this connection, it highlights the importance of including simulation as a key element in curricula, because it ensures skills in this kind of thinking and gives students the opportunity to show their ability in decision-making, critical thinking and other skills. Other authors emphasize its importance when students reflect it on their thinking process and show how it guided their actions.Regarding the practice based on simulation models, a study shows hthinking and givr skills. Other  actions.. The same author suggests the use of high-level questions to stimulate reason more than memory. He also suggests assigning an observer, who will ensure analysis and reflection on patient safety, communication, teamwork and leadership, among others. The reflection of the group around the whole process carried out will be the end of the laboratory.There is efficiency of simulation laboratories when accompanied by active strategies, such as the conceptual map before each laboratory session, a visual aid that allows the concepts, objectives, justification, expected results and possible complications to be described in a logical manner if the procedure is not carried out in the appropriate manner. The sag others. The reboratory,34..Another study concluded that simulation as a pedagogical method allows students to recognize, interpret and integrate new information with previous knowledge in order to make decisions about the best direction to follow. The authors state that simulation, as an educational method, provides an opportunity to systematically structure learning to help students acquire deep content knowledge and to facilitate the development of thought processes; that simulation experiences stimulate students’ RACT skills and help them become more competent in caring for patients in complex conditions..We agree with what has been found in other studies emphasizing that simulation laboratories by themselves do not guarantee the development of RACT skills, but if combined with other strategies and implemented with adequate pedagogy, the results will be much more effective in terms of CT skills,-38..It is also possible to find correspondence with that was discovered in the State of the Art of scientific production in RACT in the Andean region. The students perceive that “Clinical simulation is a valuable strategy for the acquisition, complementation and integration of the theoretical part with the practical part, because it seeks to make decisions according to the CT”.The evaluation of the subjects is cumulative and formative. In some cases, a diagnosis of the level of the student’s participation in the subject is made; it is evaluated in the intermediate and at the end with the objective of promotion to another level. In other cases, a teaching-learning balance is done to verify the fulfillment of the objectives and competences. Self-evaluation and heteroevaluation are increasingly used, implying a process of reflection, analysis and self-criticism..Precisely, evaluation appears as one of the weakest points when analyzing the presence of RACT in curricula. Therefore, we agree that the “best teaching practice begins by establishing learning outcomes and continues with a focus on helping the student to achieve satisfactory results”. If the proposal is to achieve a higher order thinking, the evaluation will be oriented towards the synthesis, analysis and evaluation of knowledge.Overall, the strong approaches to RACT training formulated at HEI, HEIN, as evidenced by some of the teaching and learning strategies presented in the subjects, become much weaker in the evaluation process, with predominance of traditional evaluation models, and in some cases, the intention to evaluate RACT is outlined.The curricula of Colleges and Schools of Nursing in the Andean region explicitly contemplate reflective and critical thinking in their mission, vision, objectives, graduation profile and didactic strategies, and implicitly as integral formation. However, there is a tension between what is proposed by the HEI and HEIN and what is implemented and evaluated in the subjects. The presence of RACT in the proposed didactic strategies is much more evident, but it is not sufficiently objective or explicit in the evaluation processes.Despite the great diversity of pedagogical models, there is a clear intention to facilitate the development of RACT. In addition, although a constructivist model is proposed centered on the student, dialogical, active, reflexive, innovative and critical, this model is more centered on the teacher than on the student; on knowledge over a relationship between equals; more on results than on the learning process. Likewise, knowledge is considered as something finished, fixed and the ultimate truth.In order to be able to teach the RACT to the nursing student it is necessary to include it in the nursing curriculum, teachers who are professionals in the areas of Education and Nursing and with RACT in their training. Teachers should create spaces for the development of RACT, know and implement the different and complementary didactic strategies that facilitate its learning and that analyze the students in relation to the level of RACT achieved.The authors of this article suggest that the projects currently developed with teachers and students in Ibero-America should be finalized and retaken with the implementation and evaluation of strategies that value the development of RACT.RACT is considered an indispensable element in personal and professional development, in order to have autonomy, confidence, the ability to make decisions, reach clinical judgment and, the most important, provide individualized, comprehensive and human nursing care. In summary, graduates should be able to work as members of the health team with sufficient clarity of the role and identity they should have, because they have to integrate and experience the four paradigms of the Nursing.The complexity of the project due to the number of participating countries and the different research groups;The large number of public and private nursing schools and colleges in the Andean region;The limitation in accessibility to the complete information of the curricula of each institution;The minimal presence of information on the official web pages of each institution, school or nursing college;No response and lack of interest from different schools and nursing colleges, public and private, to participate of this project;Limited access of current and recent updates of the curricula of nursing colleges to develop this project.The research group made efforts to reduce these limitations and devised multiple options that were proposed to the institutions, in order to facilitate the provision of information and its complementation when necessary.The innovation and contributions expected with this research are based fundamentally on documenting and analyzing of the diverse existing evidences about if RACT is contemplated in the nursing curricula or not, the strategies used by teachers to create and promote it in nursing students and the evaluation processes employed. It provides insights about how RACT’s competence in nursing is addressed in the context of the Andean region and other regions of Ibero-America, its weaknesses and strengths, as well as the improvements that can be made. The final intention of the research is to offer, as a network and collegial body, proposals for teaching, learning and evaluation that will enable the empowerment of new generations of nurses, using RACT as a center of innovation and development.


The development of microdevices for blood analysis is an interdisciplinary subject that demands an integration of several research fields such as biotechnology, medicine, chemistry, informatics, optics, electronics, mechanics, and micro/nanotechnologies.Over the last few decades, there has been a notably fast development in the miniaturization of mechanical microdevices, later known as microelectromechanical systems (MEMS), which combine electrical and mechanical components at a microscale level. The integration of microflow and optical components in MEMS microdevices, as well as the development of micropumps and microvalves, have promoted the interest of several research fields dealing with fluid flow and transport phenomena happening at microscale devices. Microfluidic systems have many advantages over macroscale by offering the ability to work with small sample volumes, providing good manipulation and control of samples, decreasing reaction times and allowing parallel operations in one single step. Despite the enormous scientific achievements that microfluidics have had in the last decades in the field of biomedical applications, this technology is still considered in an early stage, with some pullbacks, such as the difficulty to achieve a cost-effective large-scale production, and a lack of complete understanding of the physics of fluids at the microscale level over the biological species. Consequently, enormous efforts have been performed in microfabrication and microfluidics research to enhance the potential of microdevices to develop portable and point-of-care diagnostic devices, particularly for blood analysis. In this special issue, Catarino et al.  present Additionally, the special issue also contains 10 research papers covering different subjects related to microfluidic structures and cells characterization. Particularly, Kawaguchi et al.  have proThree of the research papers focus are focused on assessing the deformability of RBCs in microchannels ,4,5. TakFaustino et al.  have preVilas Boas et al.  reportedKang and Kim  studied Ponmozhi et al.  developeFour research papers studied clinical applications of microfluidic devices, in particular for quantification of tumor markers, as well as the characterization of the morphological properties of other cell cultures and counting cells. In particular, Sugita et al.  developeSince metastatic cancer cells are known to have a smaller cell stiffness than healthy cells, Nakamura et al.  developeGao et al.  developeFinally, Fang et al.  presenteWe hope this issue can provide an opportunity to the engineering and biomedical community, and those who are interested in the general field of MEMS and micro/nanofluidics, to access novel knowledge and information, especially in its applications to biomedical areas. Particularly, we hope this issue can contribute as a display of the latest achievements, breakthroughs, challenges and future trends in microdevices for diagnostics and blood analysis, micro- and nanofluidics, technologies for flows visualization, MEMS, biochips and lab-on-a-chip devices and their application to research and industry. Finally, we would like to congratulate, acknowledge and thank all the authors for submitting their original manuscripts to this special issue, as well as all the reviewers for the time and help to improve the quality of the submitted papers.


However, it is also essential to understandintersectoriality as a technical, administrative and political process that involvesnegotiation and distribution of power, resources and capacities  between the different sectors; and that, therefore, not only demand of asocial vision or a political intention of governance, but also of the development of newmanagement capacities and new institutional commitments.The conceptual framework for action on the social determinants of health revealedthat, in the intersectoral actions, and because of the resistance generated by a loss oforganizational autonomy, a sectoral logic prevails that hinders cooperation, thedistribution of responsibilities and an operational action. In addition, governments donot promote the decentralization of power and the empowerment of civil society.Likewise, the policies are fragmented and with discontinuity in their implementation,management and inspection. Finally, gender and ethnicity, as axes of inequality, as wellas poverty, remain “accounts pending” to implement intersectoral projects. Nevertheless,it also showed that successful intersectoral actions are presented in combination withstrong community participation strategies.A recent scoping reviewThis leads us to think that Health Promotion , the creation of networks , and Health Assets Model  are the keys to face the SHI from an integrationintersectoral approach that drives “Health in all policies”, allowing the definition ofpolicies and programs together among all sectors, and whose starting point iscross-cutting management.The National Strategy of Equity in Health of the Ministry of Health, Social Services andEquality (2012) of the government of Spain, marked four lines of work, the second being"promoting and developing intersectoral knowledge and tools", through the creation ofsectoral bodies, the inclusion of intersectoral objectives in all health plans, equitytraining in the health sector and awareness of the importance of SHI.The intersectoriality cannot be contemplated without Public Engagement, which entails anew model of governance. In this regard, the Madrid City Council launched in 2017 thePlan "Madrid City of Care"(4), a strategy of intersectoral action that puts thesustainability of life at the heart of municipal action, seeking a new relationship withcitizens, from the ethics of care, focused on both community empowerment and respect forthe autonomy and diversity of people. It is still early to have results from thisambitious plan, but very encouraging experiences have already been set in motion  that will surely make Madrid acity with greater equity and consequently with more health.To conclude, I would like to emphasize that an intersectoral approach cannot be carriedout without the social participation of all stakeholders. Intersectoriality and socialparticipation are an indissoluble binomial to resolve SHI.


The demographic transition, population aging, and the epidemiological transition in Mexico have modified the burden of the disease profile, and impose important economic, social, and health care challenges, particularly old-age and disability-related care dependency. We describe old age health and dependency conditions, and analyze the supply of services to dependent population, including aging and disability norms and policies, the role of the government and the private sector (profit & non-profit) in the provision of related services. Based on the analysis, it is clear that public strategies for care dependency are practically non-existent and that policies aimed at these populations focus on guaranteeing access to basic health services, an economic income, and social integration. Also, there are no support strategies for family caregivers who currently carry most of the care work. Care dependency strategies to support those who need them as well as those who currently provide them are urgently needed.


Nowadays pesticide residues in agricultural products have become an important challenge and a serious threat to human food security and health. Reduction of pesticides residues should be taken into consideration by public health authorities because of environmental and health problems. The harmful effects of pesticides in humans have included cancer, congenital anomalies, heart disease, Parkinson’s disease and Alzheimer’s disease . HoweverWhile total consumption of agricultural pesticides in developing country accounts for one-third of the world, most acute and chronic pesticide-induced diseases occur in these countries . AccordiThe conditions of the production, distribution and administration of pesticides, the high cost of legal pesticides, the poverty among most farmers and their lack of knowledge about risk of excessive exploitation of pesticides, and finally, lack of strict rules have been resulted the use of nonstandard pesticides in agricultural products , 7. The If the HI is less than 1, there is no obvious risk to the population. However, if it is more than one, it is threatening for consumer health. Using this indicator, the risk of pesticides can be shown quantitatively, and managerial decisions could be made more feasible . In someConsidering the potential health risks of contaminated vegetables and fruits, it is necessary to monitor the concentration of pesticides in vegetables and fruits periodically, and to create strict rules and regulations for proper use of pesticides. In this regard, due to various food habits and different levels of agricultural product consumption in the world, apart from measuring the concentration of pesticide residues, the HI should be evaluated.


Due to the increasing incidence of gastrointestinal (GI) tumors, more and more importance is attached to radical resection and patients' survival, which requires adequate extent of resection and radical lymph node dissection. Blood vessels around the gastrointestinal tract, as anatomical landmarks for tumor resection and lymph node dissection, play a key role in the successful surgery and curative treatment of gastrointestinal tumors. In the isolation of subpyloric area or hepatic flexure of the colon for gastrectomy or right hemicolectomy, lymph node dissection and ligation are often performed at the head of the pancreas and superior mesenteric vein, during which even a minor inadvertent error may lead to unwanted bleeding. Among these blood vessels, the venous system composed of Henle's trunk and its tributaries is the most complex, which has a direct influence on the outcome and postoperative recovery of the patients. There are many variations of Henle's trunk, with complicated courses and various locations, attracting more and more researchers to study it and tried to analyze the influence of its variations on gastrointestinal surgeries. We characterized various variants and tributaries of Henle's trunk using autopsy, vascular casting, 3D CT reconstruction, intraoperative anatomy, and Hisense CAS system and summarized and analyzed the tributaries of Henle's trunk, to determine its influence on GI surgeries. Resection of tumor along blood vessels and lymph node dissection has been the basic procedures in the surgical treatment of GI tumors. Therefore, understanding of the anatomy and variations of the blood vessels determines the result of the surgery and prognosis of the patients. In recent years, Henle's trunk has attracted more and more attention because of its special anatomical position and the role as an anatomical landmark in GI surgeries, and more and more studies were done on it. Various methods have been employed to identify the course and variations of Henle's trunk usage, suggesting its clinical importance and variability and complexity. This study reviewed the definition, construction, variations, and significance in gastrocolic surgeries of Henle's trunk.The concept of gastrocolic venous trunk was first proposed by Henle  in 1868.There are several variations in the formation of the GTH that depend on the number of tributaries of the right colic, which are mainly classified as bipod, tripod, and tetrapod. The right colic vein (RCV) and middle colic vein (MCV) are defined as the tributaries from the marginal veins of the ascending and transverse colon, respectively. When more than two RCVs or MCVs are present, the thickest vein is defined as the main vein, while the thinner vein is called the accessory vein. The SRCV is defined as the tributary from the marginal veins of the hepatic flexure.Studies on blood vessel variations using autopsy and vascular casting have obtained accurate results, but failed to identify some rare variants due to small samples. Results of nearly a hundred studies on Henle's trunk using autopsy and vascular casting are summarized in Surgical procedures are actually based on the anatomy of organs and vasculature, and the anatomy of the complex vasculature, in particular, has a direct influence on the success of surgery. Henle's trunk, a both relatively undiversified but also variable venous trunk, is a key to many surgeries, especially those in the stomach, pancreas, and right side of the colon, which involves the three most common tributaries of Henle's trunk: RGEV, ASPDV, and colic veins. Intraoperative studies on Henle's trunk were summarized in In the 21st century, rapid development of radiology, especially 3D CT reconstruction, enables the establishment of 3D image of the lesion preoperatively. The 3D reconstruction of blood vessels enables the visualization of the patients' vasculature, allowing surgeons to predict difficulties in the procedure and develop appropriate treatment plans. Recent studies on Henle's trunk variations using 3D CT reconstruction are summarized in CAS system, a virtual stereotactic surgical system developed by our hospital in collaboration with Hisense group, can obtain virtual images of the patients' lesions preoperatively, providing basis for the treatment and accurate navigation for the surgery. Recently, Hisense CAS system is used to obtain images of Henle's trunk for the study of its variations, in order to guide the development of surgical plans. Our study included a total of 120 patients, with Henle's trunk identified in 102 (85.0%) of them. We classified Henle's trunk into 2 types and 10 subtypes, and the most common one is those formed by SRCV, as a colic tributary, and GEV and ASPDV, which is found in 31.4% of all patients .In studies using all of the four approaches, expected for intraoperative anatomy, Henle's trunk was identified in more than 80% of patients, suggesting a stable existence of Henle's trunk in the human body . FrequenLymph node metastasis is the main route of metastasis of gastric cancer, and radical dissection of lymph node during the surgery had a direct influence on the outcome and prognosis , 14. TheComplete mesocolic excision (CME) was first proposed by Hohenberger et al. in 1992 on the basis of embryology and anatomy, which brought about a revolution in the radical treatment of colon cancer , 23. CMEIn conclusion, Henle's trunk, which connects the stomach and colon-draining veins, plays an important role in surgeries for the stomach and colon and shall be isolated for vascular ligation and lymph node dissection in many surgical procedures, especially after the rapid development of laparoscopic and robot-assisted surgery in recent years. However, the intraoperative anatomy of Henle's trunk is challenging because of its fixed position and variable combinations of tributaries, which make it difficult to predict its course and lead to increased incidence of bleeding and complications. Many studies have been done in recent years using various radiological approaches to analyze and summarize the variations of Henle's trunk and gained great achievements, which enables acquisition of knowledge of its tributaries and variation preoperatively, to ensure the outcome and prognosis of the patients –12, 27.