Instituto Mexicano Del Seguro Social Research Articles

SARS-CoV-2 infection by trimester of pregnancy and adverse perinatal outcomes: a Mexican retrospective cohort study

ObjectiveConflicting evidence for the association between COVID-19 and adverse perinatal outcomes exists. This study examined the associations between maternal COVID-19 during pregnancy and adverse perinatal outcomes including preterm birth (PTB),...

Survival Outcomes of Patients With Breast Cancer in a Mexican Population.

The Instituto Mexicano del Seguro Social is a tripartite contribution providing care to more than 74 million beneficiaries, representing more than 50% of the country's general population. This study aims to describe the survival outcomes and clinicopathologic characteristics of patients with breast cancer at our Center. A retrospective cohort of patients with breast cancer treated between January 2012 and December 2020 was conducted. Survival outcomes were assessed using the Kaplan-Meier method. Univariate and multivariate analyses were performed using a Cox proportional hazards model. There were 5,264 patients included with a median follow-up of 54.9 months. Forty-three percent (n = 2,274) were diagnosed in stage I-IIA, 43.1% (n = 2,269) in stage IIB-III, and 7% (n = 383) in stage IV. At 5 years, disease-free survival was 74.9% (95% CI, 73.5 to 76.3) and overall survival (OS) 90.4% (95% CI, 89.4 to 91.3). For stage IV, it was 22.7% (95% CI, 17.3 to 28.5). High histologic grade (hazard ratio, 1.51 [95% CI, 1.34 to 1.7]; P < .001) and lymphovascular invasion (LVI; hazard ratio, 1.85 [95% CI, 1.62 to 2.1]; P < .001) were associated with a higher risk of recurrence. Histologic grade and LVI should be considered in the decision to treat with adjuvant chemotherapy in sites where genomic signatures are not available. Our OS data are comparable with other Mexican series; however, it is lower in stage IV. Much remains to be done at the national level, mainly regarding access to additional therapies for each breast cancer subtype. This work contributes to the evaluation of areas for improvement in outcomes in our population.

Gradual and synergistic correlation of tumor thickness and histological grade in penile invasive carcinomas

Histological grade and depth of invasion are among the best outcome pathological predictors in penile cancer. The TNM system is based on a combination of both for some stages. It is assumed that high-grade and deep tumors carry the worst prognosis, and the opposite occurs with superficial and low-grade neoplasms. However, there is no systematic evaluation of the phenomenon. We studied 147 patients from the Hospital de Oncologia - Instituto Mexicano del Seguro Social (period 2000 to 2013). They were treated by total or partial penectomies. Lymph node involvement was evaluated by bilateral inguinal node dissection (126 cases) or ultrasonography (21 cases). Tumor thickness was measured in mm from tumor surface to deepest invasion point, using a cut-point for superficial (≤10 mm) vs deep (>10 mm) tumors. Histological grade was from 1 to 3 according to WHO and AFIP criteria and considering G1 and G2 as low-grade and G3 as high-grade. Average age was 62 (26–98) years old. Tumor thickness mean was 15 mm (2–30 mm). G1, G2 and G3 tumors corresponded to 19 (13 %), 48 (33 %), and 80 (54 %) cases, respectively. Follow-up ranged from 10 to 82 months (median: 57 months). Fifty-three (36 %) patients died of disease. There was an overall correlation of tumor thickness and grade in most of the cases. Low-grade tumors were encountered in 92 % (12/13 cases) of superficial tumors. Deep tumors showed high-grade in 75 % of cases (73/97 cases). Superficial tumors with low histological grade had negative inguinal nodes and no mortality whereas deep tumors showing high histological grade were associated with high metastatic risk to lymph nodes (62/73 cases) and mortality (52/73 cases). Out of 24 deep tumors with low histological grade, seven had nodal spread (29 %) but only one died of disease. No outcome difference was found in HPV associated vs HPV independent tumors. Tumor thickness and grade are important synergistic and predictive pathological factors in relation to prognosis.

Changes in Neonatal Intensive Care Unit statistics during the COVID-19 pandemic.

With the identification of COVID-19 disease in China, a pandemic began that affected health-care systems. The Neonatal Intensive Care Unit (NICU) of the Hospital de Ginecobstetricia del Centro Médico Nacional de Occidente experienced an increase in patient flow as part of the COVID-19 strategy of the Instituto Mexicano del Seguro Social (IMSS). This study aimed to analyze the impact of the COVID-19 pandemic on neonatal care and mortality indicators in our unit. We conducted a retrospective study to compare the number of hospital births, pre-term newborns (PTNB), NICU admissions, and deaths. Changes in frequencies between 2019 and 2021 were analyzed using Poisson distribution. Changes in PTNB births, proportion of admissions, and deaths/NICU discharges were analyzed by z-test for two proportions. Between 2019 and 2021, the number of births increased by more than 2-fold. NICU admissions increased from 770 in 2019 to 1045 in 2021 (p < 0.01). The ratio of deaths/discharge from the service was 16.9% in 2019 and 13.1% in 2021 (p = 0.02). Mortality indicators in the NICU decreased from 2019 to 2021, even with the increase in the number of patients admitted during the COVID-19 pandemic.

Combined Nutrition in Very-Low-Birth-Weight Preterm Infants in the Neonatal Intensive Care Unit.

Background Adequate nutritional support is crucial for achieving optimal growth and development in very-low-birth-weight (VLBW) preterm infants. This study evaluated the efficacy of combined nutrition (CN) (parenteral plus enteral nutrition (EN)) as an alternative nutrition protocol for VLBW infants in the neonatal intensive care unit (NICU). Methods This retrospective cohort study collected clinical and growth data from the medical records of VLBW infants weighing between 1,000 and 1,500 grams in the NICU of the Hospital of Obstetrics and Gynecology "Dr. Víctor Manuel Espinosa de los Reyes Sánchez" of the Centro Médico Nacional "La Raza" Instituto Mexicano del Seguro Social, Mexico. Parenteral nutrition (PN) alone or CN (PN plus EN) was used for nutritional management. Statistical tests, such as Student's t-test, Mann-Whitney U test, and chi-square test as appropriate, were used to compare the clinical characteristics and growth data of the two groups, and relative risk was calculated to determine the probability of comorbidities according to feeding type. Statistical significance was set at p<0.05. Results The study included 90 VLBW infants, with 27 receiving PN alone and 63 receiving CN. No statistically significant differences were found concerning sex, age, or Apgar score. The CN group showed better weight gain with statistically significant differences at 28 days (p=0.002), with no increase in the relative risk of necrotizing enterocolitis (NEC) or other complications. Conclusions The CN protocol met the caloric and nutritional needs, without increasing morbidity and mortality. The protocol had a positive impact on weight gain and a shorter NICU stay and should be considered as a nutritional alternative for VLBW infants.

[Aswer to "Comment on article "Bibliometric analysis of scientific publications on COVID-19 elaborated by staff of the Instituto Mexicano del Seguro Social""].

We thank the group headed by Jorge Valencia Alonso for taking the time to review in detail and prepare the letter about our article entitled: " Bibliometric analysis of scientific publications on COVID-19 elaborated by staff of the Instituto Mexicano del Seguro Social", which has recently been published in the Medical Journal of the Mexican Social Security Institute. Based on your observations and comments, we allow ourselves to make the following clarifications following the same sequence of your letter to the Editor.

[Comment on articule "Bibliometric analysis of scientific publications on COVID-19 elaborated by staff of the Instituto Mexicano del Seguro Social"].

In this letter to the editor, some doubts are expressed about the methodology used in the article Bibliometric analysis of scientific publications on COVID-19 elaborated by staff of the Instituto Mexicano del Seguro Social with the purpose of clarifying them and strengthening the scientific rigor with which it was carried out the investigation. The replicability of the studies is essential for other researchers to be able to assess the quality of the study and the validity of its results, in addition to ensuring the transparency of the science.

[Academic satisfaction in residents of the north zone, Mexico City].

Resident academic satisfaction has been linked to academic performance and quality of care. To analyze the perception of academic satisfaction in medical residents of the North Decentralized Administrative Operation Body 2 of the Instituto Mexicano del Seguro Social (IMSS), north of Mexico City. Cross-sectional analytical study. A total of 346 resident physicians of different specialties and academic degrees were found, enrolled in the residence halls in the northern zone of the IMSS, Mexico City from January to February 2022. The dependent variable was the level of academic satisfaction. Descriptive and inferential statistics and p ≤ 0.05 were produced for statistical significance. The level of high satisfaction was 80.6% and the level of poor or low satisfaction was 1.7%. The dimension most affected in the negative bases was that of "Perception of teaching" in which 13% of the doctors surveyed refer to the need for some retraining of teachers. The best qualified dimension was "Perception of the role of autonomies" where 35.3% have an excellent perception of their personal work. The highest degree of satisfaction decreased during the second year. There is a high degree of satisfaction among resident doctors, however it is necessary to work to improve satisfaction in the remaining 20%.

Survival outcomes and clinicopathological factors analysis of breast cancer patients. A single-institution cohort from 2012 to 2020 in a Mexican population.

e13104 Background: In Mexico, The Instituto Mexicano del Seguro Social (IMSS) is a tripartite contribution which provides care to more than 74 million beneficiaries, which represents more than 50% of the general population of the country. Although Mexican breast cancer statistics have been reported, it is imperative to know the updated statistics on the epidemiology in our Institution. The aim of this study is to describe the survival outcomes and the clinical-pathological characteristics of patients with breast cancer. Methods: Records of breast cancer patients treated at the Oncology Hospital from Centro Medico Nacional Siglo XXI of IMSS, from January 2012 to December 2020 were included. We analyzed clinical and demographic characteristics of the population, as well as survival outcomes at 5-years. Results: A cohort of 5,264 patients was included. Median follow up was 54.9 months. Forty-three percent (n = 2,274) were diagnosed in early-stage breast cancer (I–IIA), 43.1% (n = 2,269) in stages IIB-III, and 7% (n = 383) in stage IV. The most common immunophenotype was hormone receptor (HR) positive, HER2-negative (70.8%, n = 3,726). HER2-positive represents 19.3% (n = 1011), among HR-positive were 12.4% (n = 650) and HR-negative, 6.9% (n = 361). 527 patients (10.1%) were triple negative. At 5-years, disease-free survival was 74.9% (95% CI, 73.5 to 76.3) and overall survival was 90.4% (95% CI, 89.4 to 91.3). High histologic grade (HR 1.51; 95% CI, 1.33 to 1.7; p &lt; 0.001) and lymphovascular invasion (HR 1.84; 95% CI, 1.62 to 2.1; p &lt; 0.001) were associated with higher risk of recurrence. Adjuvant chemotherapy was significantly associated to a 42% reduction in the risk of recurrence, HR 0.58 (95% CI, 0.49 to 0.69; p &lt; 0.0001), and 54% in the risk of death, HR 0.46 (95% CI, 0.33 to 0.63; p &lt; 0.0001) in stage III. Lobular histology was also associated with worse survival, HR 1.41 (95% CI, 1.069 to 1.859; p = 0.015). Conclusions: An update of breast cancer Mexican patients treated at IMSS is presented. We highlight the impact of adjuvant treatment and pathological risk factors for recurrence and death. This work can contribute to evaluate areas for improvement in management and outcomes in our population.

MSH-5: malignant knee tumors timely detection index.

Bone neoplasms are usually misdiagnosed causing a delay in their treatment. Bone neoplasms are usually confused with tendinitis, 31% of the cases corresponds to osteosarcomas and in 21% to Ewing's sarcomas. To create a clinical-radiographic instrument of high diagnostic suspicion of knee bone neoplasms to prevent a delay in diagnosis. A clinimetric study (sensitivity, consistency and validity) was performed in the bone tumor service, Hospital de Ortopedia de la Unidad Médica de Alta Especialidad Dr. Victorio de la Fuente Narváez, Instituto Mexicano del Seguro Social, in México City. Characteristics of 153 patients were collected. For the sensitivity phase, 3 domains (signs, symptoms, and radiology) and 12 items were included. Consistency was evaluated with ICC (0.944), 95%CI (0.865-0.977), p < 0.001 and a-Cronbach (0.863). Index obtained a sensitivity of 0.80 and a specificity of 0.882 were obtained. The positive predictive value of the test was 66.6% and the negative predictive value was 93.75%. The positive likelihood ratio was 6.8 and the negative likelihood ratio was 0.2. Validity was evaluated using r-Pearson (0.894; p < 0.001). A high suspicion clinical-radiographic index was designed to detect malignant knee tumors with adequate sensitivity, specificity, appearance, content, criteria, and construct validity.

Academic-assistance activities registered by the graduates of the specialty of Emergency of the Regional Hospital No. 25 of the Instituto Mexicano del Seguro Social (1991-2018)

Academic-assistance activities registered by the graduates of the specialty of Emergency of the Regional Hospital No. 25 of the Instituto Mexicano del Seguro Social (1991-2018)

Asociación entre las características radiográficas y los tumores óseos de rodilla.

Bone neoplasms require an adequate clinical-radiographic evaluation for their diagnosis. Plain radiographs are the usual method to establish the diagnosis and evaluate differential diagnoses in the study of bone tumor pathology. To recognize the frequency of radiographic characteristics and associate them with bone tumor pathology. Radiographic data were collected from 132 patients with tumor pathology confirmed by biopsy from bone tumors service of the Traumatology and Orthopedics Hospital Unidades Médicas de Alta Especialidad Dr. Victorio de la Fuente Narváez, Instituto Mexicano del Seguro Social, Ciudad de México, during 2019. 132 patients were registered. The most frequent benign tumor was osteochondroma (27.3%), and malignant was osteosarcoma (9.8%). Active lytic lesions (odds ratio [OR]: 6.9; 95% confidence interval [95% CI]: 2.83-16.85) or aggressive (OR: 26.85; 95% CI: 3.21-224) were associated with giant cells tumors. Poorly differentiated intraosseous blast lesions of bone lineage (OR: 36.15; 95% CI: 4.4-295.5) were associated with osteosarcoma. The periosteal reaction (OR: 36.15; 95% CI: 4.4-295.5), the moth-eaten or permeative pattern (OR: 11.75; 95% CI: 1.26-109) and the central location of the lesion (OR: 3.03; 95% CI: 1.37-6.69) were associated with malignant tumor lesions. Poorly defined intraosseous blast lesions of bone lineage, periosteal reaction, and moth-eaten or permeative pattern of destruction are associated with malignant lesions.

Medical outcomes study social support survey (MOS-SSS) in patients with chronic disease: A psychometric assessment.

Currently, information on the psychometric properties of the Medical outcomes study-social support survey (MOS-SSS) for patients with chronic disease in primary health care, suggests problems in the dimensionality, specifically predominant unidimensionality in a multidimensional measure. The aim of this study was to determine the internal structure (dimensionality, measurement invariance and reliability) and association with other variables. A total of 470 patients with chronic disease from a Family Medicine Unit at the Instituto Mexicano del Seguro Social, IMSS, with a mean age of 51.51 years were included. Participants responded to the Questionnaire of Sociodemographic Variables (Q-SV), SF-36 Health-Related Quality of Life Scale-version 1.1, and MOS-SSS. Non-parametric (Mokken scaling analysis) and parametric (confirmatory factor analysis) analyses indicated unidimensionality, and three-factor model was not representative. A new 8-item version (MOS-S) was developed, where measurement invariance, equivalence with the long version, reliability, and relationship with the SF-36 were satisfactory. The MOS-SSS scale is unidimensional, and the shortened version yields valid and reliable scores for measuring social support in patients with chronic disease at the primary health care.

Gender and age-related variations in human immunodeficiency virus infection trends at the Mexican Institute of Social Security: 2003-2017.

Diagnosing and treating human immunodeficiency virus carriers has led to the identification of a higher prevalence of said infection and, therefore, of a higher risk of transmission of the virus. To find out the trend of new cases of human immunodeficiency virus infection carriers at the Instituto Mexicano del Seguro Social (IMSS) in Mexico within the 2003-2017 period. Patients affiliated to the IMSS were analyzed. Data from 42,181 newly-diagnosed cases were collected, with variations related to gender and age being observed. Age-standardized rates per 100,000 population were obtained. The highest mean annual percentage change in males was documented in adolescents (13.0, 95% CI = 9.9, 16.1). Heterogeneous trends were recorded for women, with a significant overall decrease (-2.2, 95% CI = -3.4, -1.0), but growing trends were also observed in some groups. Our results suggest that the human immunodeficiency epidemic in patients cared for at the Instituto Mexicano del Seguro Social is concentrated in males, with a growing trend particularly in adolescents.

Metabolomic Selection in the Progression of Type 2 Diabetes Mellitus: A Genetic Algorithm Approach.

According to the World Health Organization (WHO), type 2 diabetes mellitus (T2DM) is a result of the inefficient use of insulin by the body. More than 95% of people with diabetes have T2DM, which is largely due to excess weight and physical inactivity. This study proposes an intelligent feature selection of metabolites related to different stages of diabetes, with the use of genetic algorithms (GA) and the implementation of support vector machines (SVMs), K-Nearest Neighbors (KNNs) and Nearest Centroid (NEARCENT) and with a dataset obtained from the Instituto Mexicano del Seguro Social with the protocol name of the following: "Análisis metabolómico y transcriptómico diferencial en orina y suero de pacientes pre diabéticos, diabéticos y con nefropatía diabética para identificar potenciales biomarcadores pronósticos de daño renal" (differential metabolomic and transcriptomic analyses in the urine and serum of pre-diabetic, diabetic and diabetic nephropathy patients to identify potential prognostic biomarkers of kidney damage). In order to analyze which machine learning (ML) model is the most optimal for classifying patients with some stage of T2DM, the novelty of this work is to provide a genetic algorithm approach that detects significant metabolites in each stage of progression. More than 100 metabolites were identified as significant between all stages; with the data analyzed, the average accuracies obtained in each of the five most-accurate implementations of genetic algorithms were in the range of 0.8214-0.9893 with respect to average accuracy, providing a precise tool to use in detections and backing up a diagnosis constructed entirely with metabolomics. By providing five potential biomarkers for progression, these extremely significant metabolites are as follows: "Cer(d18:1/24:1) i2", "PC(20:3-OH/P-18:1)", "Ganoderic acid C2", "TG(16:0/17:1/18:1)" and "GPEtn(18:0/20:4)".

Dermatosis más frecuentes en pacientes con trasplante renal.

To determine the most frequent dermatoses in patients with kidney transplant in the dermatology consultation, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, in Mexico City, in the period from March 2016 to March 2020. Descriptive, cross-sectional study that included 153 patients with a complete medical history with prior informed consent and authorization from the hospital ethics committee. All patients presented one or more dermatoses. The most frequent were infectious (mycosis, viral) and, in decreasing order, other dermatoses (keratosis pilaris, melasma), tumorous (benign), inflammatory (seborrheic dermatitis, eczema), probably secondary to drugs and autoimmune (alopecia areata). All kidney transplant patients presented at least one dermatosis, predominantly those of infectious origin. We recommend dermatological evaluation prior to transplantation for timely diagnosis and treatment of dermatoses that could increase the morbi-mortality of patients.

Comparison of septal vs hisian ventricular synchrony in paediatric patients

Abstract Background Long-term right ventricular stimulation is associated with left ventricular dysfunction and cardiomyopathy, particularly in pediatrics and congenital heart diseases. Research has shown that pacemaker-induced cardiomyopathy can be reversed with stimulation of the Bundle of His in-adult's, however the available information on it's use in pediatrics is scarce. In this study, pacemaker carriers were analyzed over a period of 26 months to set up a protocol for improving the quality of life of patients undergoing this type of procedure. Introduction Cardiac stimulation initially arose with the aim of correcting the hemodynamic instability caused by the low cardiac output resulting from complete atrioventricular block, the next objective sought was to obtain atrioventricular synchrony and with it a more physiological functioning. Stimulation in the Bundle of His and the hisian zone induces a physiologically normal sequence of activation and thus prevents damage associated with the asynchronous pattern. Material and methods We reviewed 21 pediatric patients with pacemakers of stimulation in the Bundle of His and right septal stimulation that had echocardiographic assessment of ventricular function, as well as the assessment of ventricular synchrony. The study period included was from June 2019 to August 2021. Results The total number of patients was 21 of whom 52.4% (11) were carriers of Hisiana stimulation pacemakers, 47.6% (10) with septal pacemakers. Ventricular function was correlated between both groups without obtaining significant relevance. We obtained significant relevance in the evaluation of atrioventricular asynchrony obtaining a P&amp;lt;0.05 (P=0.01), as well as intraventricular synchrony with a P&amp;lt;0. 05 (p=0. 07). Conclusions The site of ventricular stimulation is the major determinant of the presentation or deterioration of asynchrony and ventricular function in the pediatric population. With this study we can conclude that the pacemakers of hisian stimulation are the ones that are closest to cardiac physiological activation and maintain ventricular and intraventricular atrio synchrony for a better ventricular function. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Instituto Mexicano del Seguro Social- Centro Medico Nacional de Occidente - UMAE Pediatria.

Childhood Cancer Survival, 2006-2012 Cohorts of Mexican Institute of Social Security Beneficiaries at the Central-South Region of Mexico.

IntroductionIn Mexico, the main institution of social security is the “Instituto Mexicano del Seguro Social” (IMSS), with more than 60 million enrolled individuals. This study of childhood cancer survival is the first based on complete cohorts of incident cases for the population IMSS- affiliated in the central-south region, which represents 27% of all children IMSS affiliated.MethodsIt is an observational cohort study from 2006 to 2012 to estimate the 5-year observed survival of the minors under 18 years old, identified in the Central-South Region Registry of Children with Cancer. The survival of cases was carried out through the active and passive search. Survival rates were estimated by the Kaplan–Meier (KM) method, the analysis of equality of survival functions was evaluated for some clinical variables.ResultsThe study included 2,357 minors; the 5-year observed survival was 56.1% with a time of survival median of 3.4 years, and the overall loss of follow-up was 18.4%. The 5-year survival in cases with a diagnosis of leukemia was 53.5%, while for solid tumors, it was 57.9%. The median time of death was 1 year. The types of cancer with a survival greater than 70% were group V-retinoblastoma (87.2%), IIa-Hodgkin’s lymphoma (86.8%), Xc- gonadal tumors (83.3%), Iid-miscellaneous lymphomas (80%), IVa-nephroblastoma (79.5%), and IIc-Burkitt’s lymphoma (75.4%). Meanwhile, the lowest survival rates were in group VIII-bone tumors (32.3%), III-CNS (central nervous system; 44.1%), and IX-soft tissues (46.8%).ConclusionsSurvival results in the 2006–2012 cohorts show a significant gap in relation to the goal of 60% proposed by the World Health Organization for 2030.

Downregulation of SLC16A11 is Present in Offspring of Mothers with Gestational Diabetes

Studies have identified that diseases in pregnancy affect fetal growth and development of the newborn. In Mexican population, the gene SLC16A11 has been identified as a factor that increases the risk of developing type 2 diabetes mellitus. To date, information is scarce about its expression in gestational diabetes mellitus (GDM); epigenetic modifications due to maternal hyperglycemic state could be identified early in fetal development. This study aimed to determine the SLC16A11 expression and methylation status in umbilical cord blood of newborns offspring of mothers with or without GDM. Cross-sectional, analytic study. Pregnant patients undergoing caesarean delivery with and without GDM in the Unidad Medica de Alta Especialidad Hospital de Gineco-obstetricia #4 Luis Castelazo Ayala, Instituto Mexicano del Seguro Social, were invited to participate. DNA was extracted from the mothers' blood cells, or umbilical cord blood cells of their newborns, and subjected to methylation status. Total RNA was used to evaluate the SLC16A11 expression by endpoint RT-PCR. Variables were analyzed with Student t. Values of p <0.05 were considered statistically significant. A SLC16A11 downregulation was observed for newborns, while methylation status was found in only 1 of 68 mother-child pairs. Somatometry of newborns showed no differences between groups. Differences were found in total cholesterol, triglycerides, ALT, glucose, and HbA1c. For the first time, a differential expression for SLC16A11 was observed in offspring. Downregulation in this gene expression could characterize the offspring from GDM. No difference was found in somatometry of newborns of mothers with and without GDM.

Design of a quality management system for a pharmaceutical company

This project was carried out in a company that sells and distributes medicines, it is striving to improve the quality of the service, which is why it is aiming to design the quality management system based on the processes approach and compliance with ISO 9001:2015 regulatory requirements. To fulfill the objective, the following activities were carried out: processes mapping, context analysis, risk identification, stakeholder mapping, establishment of quality policy and objectives, and development of a control plan. The results indicate the following key processes: purchases, inventories and sales, strategic prospecting, supply and support; management of human resources, technology and finance. Most influential stakeholders; in the client category, the Instituto Mexicano del Seguro Social, private hospitals and laboratories; in the provider category, PISA laboratory and independent drug distributors, in addition, the scope of the management system, policy and quality objectives were established, as well as a control plan for the system's risk management. Critical risks include not having developed mechanisms for electronic commerce and the lack of a Quality Management System. The countermeasures consider creating and designing an e-commerce store and implementing the Quality management system.