Revista Chilena de Fonoaudiología

Cover Volumen 22(1), 2023

Josué Pino Castillo — 2023-11-23

Editorial Volumen 22

Andrea Helo — 2023-11-23

Editorial

Artículos

Tamaño del léxico en niños(as) muy prematuros y prematuros extremos de 24 meses: un estudio transversal. Virginia Varela-Moraga, Constanza Arce-Montero, Camila Osorio-Saldaña, Fernanda Ramirez-Carreño y Camilo Quezada.

Experiencias de fonoaudiólogos/as al realizar telerehabilitación a niños preescolares con trastorno del desarrollo del lenguaje en contexto de pandemia. Katherine Mora Pino, Yolanda Cusquisiban Inga, Moyra Gómez Clavijo, Fernanda San Martín Cabezas y Valentina Vizcarra Castro.

Evolución de la afasia en adolescentes con secuela de ACV. Serie de casos. Jimena Gabilondo, Agustina Pereyra, Mauro Andreu y María Candelaria Saravia.

Competencias sociales y bullying en adolescentes con Trastorno del Espectro Autista y su asociación con la conducta suicida. Un estudio piloto. Carla Figueroa Saavedra, Claudia Guajardo Sáez, Virginia Guillén Cañas, Michelle Vitali Andana, Cyntia Lagos Cid, Sebastián Huentemil Collin y Valentina Rifo Riquelme.

Planificación terapéutica fonoaudiológica para el abordaje de usuarios/as adultos con dificultades comunicativas y/o lingüísticas de origen neurológico. María Cabrera-Miguieles, Consuelo Sepúlveda-Ibarra, Nicole E. Almeida-Marcos y Jaime Crisosto-Alarcón.

Evaluación de la Competencia Pragmática de Cuatro Adultos Españoles con Discapacidad Auditiva Congénita a través del Protocolo Rápido de Evaluación Pragmática - Revisado. Marina Pérez y Esther Moraleda.

Rendimiento cognitivo en personas con síndromes vestibulares: Una revisión integradora de la literatura. Patricia Alejandra Oyarzún y Osvaldo Borro.

Prevalencia de la exóstosis del conducto auditivo externo entre practicantes de surf y bodyboard en la costa central de Chile. Carlos Orellana, Paula Plaza, Cristian Poblete, Jan Karlsruher y Gonzalo Gallardo.

Effect of Sleep Quality and Duration on Jitter, Shimmer, and Harmonics-to-Noise Ratio among Colombian University Professors. María Paula Rincón Pinilla, Andrés Carrillo-González y Lady Catherine Cantor-Cutiva.

Adaptación lingüística y cultural chilena del Voice Handicap Index (VHI) y del Voice Handicap Index 10 (VHI-10). Soledad Alicia Correa Forno, Renata Rangel Azevedo y Ana Cristina Côrtes Gama.

Estudio preliminar para la validación de la versión Chilena del Vocal Tract Discomfort-VTD en población docente. Felipe Cerda Sandoval, Gerson Jara Cabrera, Verónica Bittner Schmidt, Camila Riffo Sánchez, Felipe Saballa Torrealba y Gabriela Galgano Morales.

Tipos de fibras de los músculos intrínsecos laríngeos de seres humanos: una revisión de la literatura. Christopher Fuentes Aracena.

Abordaje fonoaudiológico en proceso cicatricial post trauma facial de tejidos blandos: relato de caso clínico. María Celina Malebrán Bezerra de Mello, Natalia Andrea Cáceres Nova y Paulo Eduardo Damasceno Melo.

Impacto de la cánula nasal de alto flujo (CNAF) y ventilación mecánica no invasiva (VMNI) en la fisiología deglutoria: revisión de la literatura. Axel Pavez, Cristóbal Hernández- Escuti, Francisca Paredes Lorca, Rodrigo Jara Fuentes, Bernardita Letelier-Vera y Paula Madariaga Ovando.

Revisión de protocolos clínicos para el manejo del cuff en pacientes adultos con vía aérea artificial en hospitales públicos chilenos. Felipe Rosales Lillo, Fabiola Marín Garrido, Giovanna Monichi Montenegro y Francisca Miranda Llanos.

Dotación fonoaudiológica para la atención de pacientes adultos y pediátricos en hospitales chilenos de alta complejidad. Felipe Rosales Lillo, Nicole B. Vargas, Carolina Carrera Sáez, Anaís Mancilla Lespai, Scherly Orellana Araya, Juliette Pilgrim Hidalgo y Mabel Villegas Orellana.

Reseña

Una reseña de: The Oxford Handbook of Down Syndrome and Development. María Magdalena Muñoz.

Vocabulary size in very preterm and extremely preterm infants: a cross-sectional study

Virginia Varela-Moraga — 2023-11-23

Research shows that a significant number of children born preterm (before 37 weeks of gestation) have developmental difficulties, among them disturbances in language development. Studies indicate that some biomedical complications such as intraventricular hemorrhage (grades III and IV), periventricular leukomalacia, and bronchopulmonary dysplasia increase the probability of cognitive and/or language development disorders. Therefore, there is a need to conduct more studies that provide information that allows anticipating possible consequences in the learning process of children born prematurely. The aims of this study were to measure the early vocabulary size in very preterm and extremely preterm children (with and without biomedical complications) at 24 months of corrected age and to determine the association between the number of biomedical complications and vocabulary size. To that effect, we worked with 108 children divided into three groups: 39 high-risk preterm children (with biomedical complications), 36 low-risk preterm children (without biomedical complications associated with language and/or cognitive disturbances), and 33 full-term children. All children were evaluated using the MacArthur-Bates Communicative Development Inventory II. The results show that the vocabulary size of full-term children is significantly larger than that of preterm children and that no differences exist between the group of high-risk versus low-risk preterm children. On the other hand, vocabulary size does not correlate with biomedical complications.

Experiences of Speech-Language Therapists Providing Teletherapy to Preschoolers during the COVID-19 Pandemic

Katherine Marisel Mora-Pino — 2023-11-23

Confinement, as a sanitary measure due to the COVID-19 pandemic, has forced school systems around the world to adapt their lessons to the virtual modality. Speech-language therapists working with preschool children who present language disorders have had to modify their usual work methodology to achieve their therapeutic and educational goals. This research sought to describe the perception speech-language therapists had of their experience providing telerehabilitation to preschool children with developmental language disorder during the pandemic. The study design was qualitative with a phenomenological approach. The sample was made up of 10 female speech-language therapists, recruited through convenience sampling, who were interviewed using semi-structured interviews. The data were analyzed phenomenologically, obtaining subcodes, codes, and categories manually. The following thematic categories emerged from the analysis: evaluation of the experience, effectiveness of the virtual intervention, session preparation, and parental participation. The experiences shared during the interviews allowed us to detect critical elements related to the improvised and sudden modality change, the lack of training and/or preparation of the therapists to implement telepractice, resource administration, and a perception of ineffectiveness regarding the intervention. Although virtual interventions have been established as an alternative to in-person intervention, it is concluded that it was not widely accepted among the speech-language therapists interviewed in this research, who deemed this modality demanding and ineffective for such young children. We emphasize the importance of parental and/or caregiver commitment to achieve success during the process of teletherapy.

Post-stroke aphasia in adolescents’ progress: Case series

Jimena Gabilondo — 2023-11-23

Aphasia as a sequela of stroke is an understudied language disorder in adolescents, both in Latin America and worldwide. Although a significant number of aphasia cases improve spontaneously, it is necessary to initiate treatment as soon as possible. This cases series describes the clinical presentation and evolution of aphasia in 3 adolescents with stroke sequelae who were admitted to a neurorehabilitation facility. Two females and one male, aged between 15 and 17 years, received intensive comprehensive rehabilitation from the areas of physiotherapy, occupational therapy, neuropsychology, psychopedagogy, music therapy and speech therapy. They were evaluated with the Chilean version of the Western Aphasia Battery (WAB). After 3 months, all of them improved and evolved to a milder type of aphasia. This study shows the importance of early, intensive treatment in adolescents who are in the height of their social development, where language alteration impacts on their bonds, their groups of belonging, their mood and their academic process. Systematic assessment and follow-up are considered essential to identify the changes and progress achieved during rehabilitation.

Social Skills and Bullying and their Association with Suicidal Behavior in Adolescents with Autism Spectrum Disorder (ASD): A Pilot Study

Carla Figueroa Saavedra — 2023-11-23

Evidence suggests that Autism Spectrum Disorder (ASD) may be associated with an increased risk of suicidal ideation. In light of this situation, it becomes necessary to investigate whether social skills and bullying are factors that influence suicidal behavior. Therefore, this research explores the association between the state of social skills and experiences of bullying, and the degree of suicidal ideation in high-functioning adolescents with ASD. A pilot study was conducted with the participation of 24 high-functioning adolescents with ASD aged between 11 and 18 years. The instruments used for assessment included 1) the Okasha Scale, 2) the Aggression/Victimization Scale, and 3) the Adolescent Multidimensional Social Competence Questionnaire (AMSC-Q). Data analysis involved descriptive statistics and correlation analysis using the Spearman correlation coefficient. The results revealed an association between the level of suicidal ideation, bullying (rs 0.73; p<0.05), and specific dimensions of social skills: cognitive reappraisal (rs -0.44; p<0.05), normative adjustment (rs -0.659; p<0.05), and social efficacy (rs -0.45; p<0.05). It is concluded that there is a correlation between bullying and the degree of suicidal ideation. Additionally, it is observed that some dimensions of social competence are associated with suicidal ideation in the population of adolescents with ASD.

Planning Speech and Language Therapy Interventions for Adults with Neurogenic Communication Disorders

María Gabriela Cabrera-Miguieles — 2023-11-23

The International Classification of Functioning, Disability and Health (ICF), emphasizes the need for health interventions to be tailored to each patient's unique requirements. In Chile, there are currently no consistent guidelines for the design of treatment plans. This lack of structure for speech-language therapy interventions hinders the communication between professionals and, therefore, the possibility to plan adequate therapeutic intervention. This article aims to provide a theoretical and conceptual framework that facilitates structured therapeutic planning for adult patients with neurogenic communication and/or linguistic difficulties, following international standards. A critical review was carried out, with a narrative-conceptual structure and intentional sampling of current theoretical proposals. A set of theoretical tools is proposed within the framework of the ICF model, in order to facilitate the work of speech-language therapists.

Assessing the Pragmatic Competence of Four Spanish Adults with Congenital Hearing Loss through Protocolo Rápido de Evaluación Pragmática – Revisado

Marina Pérez-Carreño — 2023-03-08

Numerous studies reveal the oral language difficulties that people with hearing loss may present throughout their development. However, little is known about the level of pragmatic competence they achieve and how this area evolves. This research aims to address the pragmatic characteristics of four Spanish adults with congenital hearing loss through Protocolo Rápido de Evaluación Pragmática - Revisado (PREP-R, which can be translated as Quick Protocol for Pragmatic Evaluation - Revised). This test assesses different levels of pragmatics: textual, enunciative, and interactional, and also provides an indicator for general, specific, and grammatically-based pragmatic ability. The participants were assessed by videotaping spontaneous speech samples in conversation with a family member. The results indicate that, in general, the four subjects present an adequate level of pragmatic competence, which is manifested in their adjustment of speech acts. Nevertheless, they show a tendency to use compensatory behaviors to regulate their speech, such as verbal strategies that allow them to gain extra time to construct their utterances, compensatory verbal and/or paraverbal acts, and gestures that complement their verbal productions. These data indicate that, although the participants of this study show good pragmatic skills, it is necessary to continue developing intervention strategies that allow them to communicate without difficulties in different contexts and with different communication partners.

Cognitive Performance in People with Vestibular Disorders: An Integrative Literature Review

Patricia Alejandra Oyarzún Díaz — 2023-11-23

The impact of vestibular disorders on quality of life and the physical, emotional, and social spheres has been widely studied and documented. However, although functional and anatomical relationships have been found between the vestibular system and cortical areas, neuroimaging studies have established that domains like attention, memory, spatial navigation, and orientation would be involved, despite there being few studies investigating cognitive performance. This study aimed to identify and synthesize the available scientific evidence on cognitive performance in people with vestibular disorders and to analyze the methodological quality of the selected articles. An integrative literature review was carried out which surveyed the databases of ProQuest, EBSCO, PubMed, ScienceDirect, Cochrane Library, and SciELO. The studies’ methodological quality was assessed using the Downs & Black checklist for randomized and nonrandomized healthcare intervention studies. Altogether, 771 studies were found, of which 5 were selected and analyzed. The results show that the cognitive domains that are studied focus mainly on general cognitive status, visual-spatial skills, executive functions, and attention. Nonetheless, the findings are contradictory due to methodological differences (pathology studied, status of the pathology, instruments used, age of the participants, and lack of control groups, among others).

Prevalencia de la exóstosis del conducto auditivo externo entre practicantes de surf y bodyboard en la costa central de Chile

Carlos Orellana — 2023-03-10

External auditory canal exostosis (EACE), also known as surfer's ear, is a bone tissue disturbance in the outer ear, mainly caused by overexposure to cold temperatures. Considering that people who practice water sports such as surfing and bodyboarding on the Pacific coast are exposed to waters at temperatures between 12-16 °C, this study aimed to determine the prevalence and severity of EACE in surfers and bodyboarders from Reñaca and Concón, two coastal cities in the southern Pacific Ocean, during the year 2018. An EAC evaluation was carried out through video otoscopy on 67 people (134 ear canals) who practiced surfing and bodyboarding on the beaches of Reñaca and Concón, and a questionnaire was used to collect information about their practice habits. As a result, an EACE prevalence of 77.6% was found, with 61.2% being bilateral and 16.4% unilateral. Additionally, it was observed that 62.3% of the participants do not use ear protection. Based on these findings, it is possible to conclude that there is a high prevalence of EACE in surfers and bodyboarders from the central coast of Chile, which should alert both the population of people who practice these water sports and the professionals who work with auditory health of the necessity to promote a healthy lifestyle in this population.

Effect of Sleep Quality and Duration on Jitter, Shimmer, and Harmonics-to-Noise Ratio among Colombian University Professors

María Paula Rincón Pinilla — 2023-07-05

Professors who sleep 6 or fewer hours are more likely to report voice symptoms. However, only three studies have been published on this topic, basing their conclusions on self-reported surveys and displaying an overall weak methodological quality, which hinders the generalization of these results. This exploratory, correlational, and longitudinal study aimed to determine the association between sleep quality and duration and three acoustic parameters linked to voice harmonicity and quality (jitter, shimmer, and Harmonics-to-Noise Ratio [HNR]) among 24 Colombian university professors. Generalized linear models with gamma distribution were used to analyze this association. Our results indicate that the professors who reported good sleep quality had significantly lower HNR values compared with those who had a low sleep quality. Additionally, increased jitter (B= 0.10) and shimmer (B= 0.10), and decreased HNR (B= -0.05) values were found when the duration of sleep increased. In contrast, participants with good self-perceived sleep quality and a shorter sleep duration presented lower voice harmonicity compared to those with bad sleep quality and shorter sleep duration, which may be associated with the physiological and emotional effects of sleep on voice production. Considering the multifactorial nature of voice production and the exploratory nature of the present study, it is important to note that a statistically significant correlation between sleep quality and duration and voice harmonicity does not necessarily imply that sleep directly causes voice disorders, but rather suggests that sleep is a variable to be considered when analyzing and treating individuals with voice issues. These findings provide insight into the complex interplay of variables that may contribute to voice disorders and highlight the importance of considering sleep as a potential contributing factor in the assessment and management of individuals with voice issues.

Chilean Linguistic and Cross-Cultural Adaptation of the Voice Handicap Index (VHI) and the Voice Handicap Index 10 (VHI-10)

Soledad Alicia Correa Forno — 2023-03-08

The present study aimed to linguistically and culturally adapt the North American vocal self-assessment questionnaire, Voice Handicap Index (VHI), to Chilean Spanish. To this end, four direct translations of the VHI were carried out independently into Chilean Spanish. Subsequently, a general translation (GT) was agreed upon based on the judgment of three speech-language therapists. This GT was back-translated into the original language and compared with the original version by the same group of speech therapy professionals, which resulted in the first version of the Chilean Índice de Desventaja Vocal [Vocal Disadvantage Index] (IDV-Cl). This version was then applied to twenty people diagnosed with dysphonia, using a Likert scale for frequency. During the adaptation, it was deemed pertinent to make a note of the statements that were not understood or were culturally inappropriate for the Chilean vocabulary. The instrument was revised and modified based on the observations made by the participants, thus creating a second version of the IDV-Cl, which was then applied to six people diagnosed with dysphonia. No new suggestions for change were made at this stage. The IDV-Cl reflects the original version in English, both in the number of items and in the physical, functional, and emotional subcomponents that comprise it. Through the synthesis of this survey, it was also possible to obtain an abbreviated version, consisting of ten items (IDV-Cl-10). In conclusion, the cultural and linguistic equivalence of the VHI questionnaire in Chilean Spanish is established, resulting in the IDV-Cl and IDV-Cl-10 versions of this instrument.

Validation of the Chilean Version of the Vocal Tract Discomfort-VTD on Teachers: A Preliminary Study

Felipe Cerda Sandoval — 2023-02-09

Due to the vocal load to which voice professionals such as teachers are exposed, voice disorders and vocal misuse are frequently found in this group. This makes it necessary to have quick and simple assessment instruments that allow early detection of vocal symptoms. The objective of this study was to adapt the "Vocal Tract Discomfort Scale (VTD)" to Chilean Spanish and carry out a preliminary validation of this protocol on teachers. First, the original instrument was translated to Spanish by two native speakers, and then back-translated by two English experts, in order to determine the presence of agreements and discrepancies. Subsequently, a group of experts made up of two methodologists and five speech therapists with experience in the voice field performed an appearance and content validation. Criterion validity was obtained through the correlation between the Vocal Tract Discomfort Scale and the Spanish-validated version of the Voice Handicap Index as a gold-standard test, for which the first was applied to a sample of 31 teachers. The validation of the VTD scale is reliable and provides speech therapists with a simple and understandable tool that allows them to comprehend the impact of dysphonia on people, particularly on voice professionals such as teachers.

Fiber Types in Human Intrinsic Laryngeal Muscles: A Literature Review

Christopher Fuentes — 2023-07-15

The study of muscle fibers allows the composition of muscles and their functional characteristics to be understood in greater detail. In addition, it makes it possible to apply training and rehabilitation programs based on the energy pathways that regulate muscle contraction. Studying muscle fibers is generally associated with the analysis of myosin heavy chains (MHC) which provide information on the functional characteristics and properties of muscles. The objective of this study was to synthesize the available scientific evidence on the distribution of muscle fibers and myosin heavy chain isoforms present in the intrinsic laryngeal muscles of human beings. A systematic review of the literature was carried out and articles found on PubMed, EBSCOHost, and SciELO were analyzed. The findings show the presence of slow-tonic, type I, type II, type IIA, and type IIX/IIB fibers. Additionally, isoforms MHC-I, MHC-IIA, MHC-IIX, MHC-Fetal, MHC-L, and MHC-IIB can be found. In conclusion, intrinsic laryngeal muscles are composed of a combination of slow and fast fibers and MHC isoforms, derived from evolutionary adaptations and changes which have given way, among other things, to the phonetic characteristics of the human voice.

Speech-Language Therapy Approach to the Scarring Process after Facial Soft Tissue Trauma: A Clinical Case Report

Mª Celina Malebrán Bezerra de Mello — 2023-11-23

Facial soft tissue trauma can change muscle structure, affecting the functions of the stomatognathic system and causing injuries at the integumentary level, which leads to the formation of scar tissue that restricts the mobility of orofacial structures. Few reports in the specialized literature describe the approach of speech-language therapy to these injuries. Therefore, this study aims to describe the speech-language therapy approach to scarring, using myofunctional therapy, in a case of facial soft tissue trauma. A patient with soft tissue trauma in the lower third of his face was evaluated by speech-language therapy. His injury caused adhesions and contractions, which were associated with disturbances in his stomatognathic system that affected movement, sensitivity, and position, as well as his speaking, chewing, and swallowing functions. The patient attended 10 sessions over 3 months, at which point he expressed his satisfaction with the intervention and decided to end it. The final evaluation showed an improvement in lip symmetry during rest and movement, greater lip and cheek movement amplitude, adequate sensitivity, and absence of pain. Furthermore, progress was observed in orofacial functions related to swallowing (consistent lip seal and complete food retention), chewing (adequate speed and central incision), and speech (articulatory precision). The results of this case show that speech-language therapy intervention is essential in facial trauma and scar rehabilitation.

High-flow nasal cannula and non-invasive ventilation impact on swallowing physiology: review

Axel Pavez Reyes — 2023-08-08

Deglutition requires adequate coordination between breathing and swallowing. In the clinical context, the use of non-invasive ventilatory devices such as high-flow nasal cannulas (HFNC) or non-invasive ventilation (NIV) has become highly relevant in recent years. However, there is little information regarding how these devices could interfere with the physiology of deglutition. This study aimed to describe the impact of HFNC and NIV on swallowing physiology. To this end, a literature review was carried out using PubMed, Medline, Embase, Web of Science, Lilacs, and Scielo. Studies performed on populations ≥18 years old where HFNC or NIV were used were included. Studies where the population had a history of dysphagia, need for intubation, and presented neurological, neuromuscular, or respiratory diseases, among others, were excluded. The results show that HFNC could decrease the swallowing rate (with flows ≥ 20 L/min; p<.05), decrease the mean activation time of the swallowing reflex in proportion to the flow (p<.05), increase the risk of aspiration when using higher flows (>40 L/min, p<0.05), and increase the average duration of the laryngeal vestibule closure (p<.001). NIV, particularly BiPAP, could increase the risk of aspiration due to the higher rate of post-swallowing inspiration (SW-I, p<.01). Although the evidence available on this matter is limited, these results offer relevant information that should be considered when working with patients who use these ventilatory devices. Further research should be carried out to strengthen the evidence that is provided in this study.

A Review of Clinical Protocols for Cuff Management in Adult Patients with an Artificial Airway in Chilean Hospitals

Felipe Gonzalo Rosales Lillo — 2023-11-23

Previous research carried out in Chile reports that some health institutions have developed their own protocols for the management of adult patients with an artificial airway. These protocols recommend different cuff pressures, which could result in risks for the patients. There is no guideline by the Chilean Ministry of Health on this topic; furthermore, it has been observed that health professionals in Chile use inadequate cuff pressures with patients. The objective of this study was to describe the techniques and cuff pressures recommended in the protocols of Chilean public hospitals for the management of adult patients with an artificial airway. Secondary research was conducted using a descriptive design that included valid protocols used for the management of adult patients with an artificial airway in Chilean public hospitals. The project was approved by an Ethics Research Committee. The results of this study showed that most of the protocols mentioned the use of an objective technique with patients; however, they failed to mention the specific instrument. The mean minimum pressure reported in the protocols was 28.44 cmH2O, whilst the mean maximum pressure was 36.12 cmH2O. Only 23.80% of the protocols complied with the pressure values recommended by the current evidence. In conclusion, most of the analyzed protocols mention the use of an objective technique, with 68.75% of them recommending cuff pressures that exceed safe values. This could compromise the adequate care of patients during hospitalization. It is crucial that institutional protocols are updated and that the Ministry of Health develops a national guideline that provides clear instructions on this practice.

Speech-Language Therapy Staffing for Pediatric and Adult Patient Care in High-Complexity Hospitals in Chile

Felipe Gonzalo Rosales Lillo — 2023-11-23

Introduction: The Chilean Ministry of Health has developed a proposal to determine the number of professionals in health settings according to the number and type of clinical beds, for attending both hospitalised and ambulatory patients. That proposal differs with the international suggestions, which recommend one Speech Therapist per 10 clinical beds, or even more depending on each health institution. In Chile, there is just one study on this topic, which studied the number of Speech Therapists for attending hospitalised-adult patients in high-complex hospitals. Aim: To determine the Speech Therapists and the number of hours per week required for attending adults and paediatrics patients in Chilean high-complex hospitals. Methods: A descriptive, observational and transversal study was performed, including all the clinical beds available during 2022 in high-complex hospitals, for attending adults and paediatrics patients. Results: 64 high-complex hospitals were included. Of the total of Speech Therapists required, the Metropolitan region needs a 37,71%, then, the Valparaiso region a 9,60%, and the Bío-Bío region a 9,22%. 19,613.26 hours per week are required for attending both adults and paediatrics patients in high-complex hospitals. Conclusion: Considering the number and type of the clinical beds per hospital, a total of 504 Speech Therapists are required in Chile. Of them, 445 for a journey of 44 hours per week, 17 for 33 hours, 13 for 22 hours, and 29 for 11 hours. It is suggested to calculate the gap between the hours required per week per hospital, and the real contracted hours in health settings.

A Review about "The Oxford Handbook of Down Syndrome and Development"

María Magdalena Muñoz Montes — 2023-11-23