Sistemas Modernos de Contabilidad

The book deals with relevant and current issues about accounting systems, methods and records from the second decade of the 20th century. The first knowledge related to the accounting function is reflected in the univocal contribution that the author consumes with the expression to Castilian, with a particular eloquent and subtle style, without departing from scientific technicalities from another continent. This is the first accounting book in Mexico, which translates concepts and technicalities from English (England and the United States of North America) to Spanish without neglecting Mexican business functions and needs. This first contribution focuses its objective on providing knowledge to accounting slang and convergence towards case studies of real companies that started operations in Mexico, as an attempt to compensate the economy weakened by the aftermath of the Mexican revolution. Likewise, the book separates systematization from practicality until it reaches business results for decision-making by future and current accountants of that time, through financial statements that are still in force today. This legacy remains in force subject to global technological changes.El libro trata de temas relevantes y actuales acerca de los sistemas, métodos y registros contables a partir de la segunda década del siglo XX.  Los primeros conocimientos vinculados a la función de la contaduría se ven reflejados en la aportación univoca que el autor consuma con la expresión al castellano, con un estilo particular elocuente y sutil, sin apartarse de los tecnicismos científicos provenientes de otro continente. Este es el primer libro de contabilidad en México, que traduce conceptos y tecnicismos del inglés (Inglaterra y Estados unidos de Norte América) al español sin descuidar las funciones y necesidades empresariales mexicanas. Esta primera aportación, centra su objetivo en proporcionar los conocimientos al argot contable y la convergencia hacia estudios de casos de empresas reales que iniciaban sus operaciones en  México, como intento de resarcir la economía debilitada por las secuelas de la revolución mexicana. Asimismo, el libro separa la sistematización, de la practicidad hasta llegar a los resultados empresariales para la toma de decisiones de los futuros y actuales contadores de aquella época, a través estados financieros hasta hoy vigentes. Este legado permanece vigente a reserva de los cambios tecnológicos globales

Extension and application of an observation-based local climate index aimed to anticipate the impact of El Niño–Southern Oscillation events on Colombia

The Tumaco multivariate index (TMI) is a multidecadal monthly index constructed with unique time series of sea surface temperature, surface air temperature and rain measured at Tumaco bay, in the southern Pacific coast of Colombia, and available since 1961. In this work, this index is re-evaluated after the addition of in situ sea level data, and its properties for different standardization periods are compared against oceanic El Niño–Southern Oscillation (ENSO) and other derived indices. In particular, we propose a modified TMI, hereinafter referred as TMI4, whose potential to identify the expected sign and the amount of future variations of rain induced by ENSO events in Colombia is analysed for selected extreme episodes. Results indicate that after the inclusion of sea level data, TMI4 can anticipate the development of El Niño events before the ENSO 3 and some other sea surface temperature-based regional indices, although its predictability depends on the ENSO type (canonical or Modoki). The explanation is that sea level includes new information into TMI4 on the onset of El Niño events. In particular, the signal of intraseasonal sea level anomalies carried by downwelling Kelvin waves is detected at Tumaco tide-gauge. Moreover, the analysis of the differences, both in magnitude and spatial distribution, of rainfall anomalies induced by positive (El Niño) and negative (La Niña) ENSO events characterized by TMI4 are regionally presented. As a result, we find that TMI4 is especially suited for extensive northern and western areas of mainland Colombia. For completeness, in the appendix we briefly introduce the semi-automated implementation of TMI4, including a visual interface, which is currently being tested by personnel within the operational oceanography area at Centro de Investigaciones Oceanográficas e Hidrográficas del Pacífico (Dimar-CCCP).J. M. Sayol, L. M. V asquez and J. L. Valencia thank funding from Centro de Investigaciones Oceanográficas e Hidrográficas del Pacífico – Dirección General Marítima de Colombia (Dimar), Ministry of National Defense of Colombia. J. M. Sayol also thanks the joint funding received from the Generalitat Valenciana and the European Social Fund under Grant APOSTD/2020/254. The work of DGG and IV was partially supported by Spanish Project RTI2018-093874-B-100 funded by MCIN/AEI/10.13039/501100011033 and by the Generalitat Valenciana Grant PROMETEO/2021/030. A. Orfila acknowledges financial support from FEDER/Ministerio de Ciencia, Innovación y Universidades – Agencia Estatal de Investigación through MOCCA project (grant # RTI2018-093941-B-C31)

Guía de práctica clínica para la prevención, diagnóstico y manejo de infecciones asociadas al acceso de hemodiálisis en el Seguro Social de Salud del Perú (EsSalud)

Background: This article summarizes the clinical practice guidelines (CPG) for the prevention, diagnosis and management of infections associated with hemodialysis access of the Peruvian Health Social Security (EsSalud). Objective: To provide clinical recommendations based on evidence for the prevention, diagnosis and management of infections associated with hemodialysis access in EsSalud. Material and Methods: A guideline development group (GDG) was established, including medical specialists and methodologists. The GDG formulated 7 clinical questions to be answered in this CPG. Systematic searches of systematic reviews and primary studies (when pertinent) were conducted in PubMed, and CENTRAL (Cochrane) from November 2019 to March 2020. The evidence was selected to answer each of the clinical questions. The accuracy of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the GEG used the GRADE methodology to review the evidence and formulate the recommendations, the points of good clinical practice and the treatment flowchart. Finally, the CPG was approved with Resolution No. 116-IETSI-ESSALUD-2020. Results: The present CPG addressed 7 clinical questions of four topics: prevention, diagnosis and treatment. Based on these questions, 12 recommendations (11 strong recommendations and 1 weak recommendation), 33 points of good clinical practice, and 2 flowcharts were formulated. Conclusion: This paper summarizes the methodology and evidence-based conclusions from the CPG for the prevention, diagnosis and management of infections associated with hemodialysis access of EsSalud.Introducción: El presente artículo resume la guía de práctica clínica (GPC) para la prevención, diagnóstico y manejo de infecciones asociadas al acceso de hemodiálisis en el Seguro Social del Perú (EsSalud). Objetivo: Proveer recomendaciones clínicas basadas en evidencia para la prevención, diagnóstico y tratamiento de infecciones asociadas al acceso de hemodiálisis en EsSalud. Material y Métodos: Se conformó un grupo elaborador de la guía (GEG) que incluyó especialistas y metodólogos. El GEG formuló 7 preguntas clínicas. Se realizó búsquedas sistemáticas de revisiones sistemáticas y estudios primarios en PubMed y CENTRAL de Cochrane entre noviembre del 2019 y marzo del 2020. Se seleccionó la evidencia para responder a las preguntas clínicas planteadas. La certeza de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). El GEG usó la metodología GRADE para revisar la evidencia y formular recomendaciones, los puntos de buena práctica clínica y el flujograma de tratamiento. Finalmente, la GPC fue aprobada con Resolución N° 116-IETSI-ESSALUD-2020. Resultados: La presente GPC abordó 7 preguntas clínicas, divididas en tres temas: tamizaje, diagnóstico, estadiaje y tratamiento. En base a estas preguntas se formularon 12 recomendaciones (11 fuertes y 1 condicional), 33 puntos de buena práctica clínica y 2 flujogramas de manejo. Conclusión: El presente artículo resume la metodología y las conclusiones basadas en evidencias de la GPC para la prevención, diagnóstico y tratamiento de infecciones asociadas al acceso de hemodiálisis en EsSalud

First Latin American clinical practice guidelines for the treatment of systemic lupus erythematosus: Latin American Group for the Study of Lupus (GLADEL, Grupo Latino Americano de Estudio del Lupus)-Pan-American League of Associations of Rheumatology (PANLAR)

Systemic lupus erythematosus (SLE), a complex and heterogeneous autoimmune disease, represents a significant challenge for both diagnosis and treatment. Patients with SLE in Latin America face special problems that should be considered when therapeutic guidelines are developed. The objective of the study is to develop clinical practice guidelines for Latin American patients with lupus. Two independent teams (rheumatologists with experience in lupus management and methodologists) had an initial meeting in Panama City, Panama, in April 2016. They selected a list of questions for the clinical problems most commonly seen in Latin American patients with SLE. These were addressed with the best available evidence and summarised in a standardised format following the Grading of Recommendations Assessment, Development and Evaluation approach. All preliminary findings were discussed in a second face-to-face meeting in Washington, DC, in November 2016. As a result, nine organ/system sections are presented with the main findings; an 'overarching' treatment approach was added. Special emphasis was made on regional implementation issues. Best pharmacologic options were examined for musculoskeletal, mucocutaneous, kidney, cardiac, pulmonary, neuropsychiatric, haematological manifestations and the antiphospholipid syndrome. The roles of main therapeutic options (ie, glucocorticoids, antimalarials, immunosuppressant agents, therapeutic plasma exchange, belimumab, rituximab, abatacept, low-dose aspirin and anticoagulants) were summarised in each section. In all cases, benefits and harms, certainty of the evidence, values and preferences, feasibility, acceptability and equity issues were considered to produce a recommendation with special focus on ethnic and socioeconomic aspects. Guidelines for Latin American patients with lupus have been developed and could be used in similar settings.Fil: Pons Estel, Bernardo A.. Centro Regional de Enfermedades Autoinmunes y Reumáticas; ArgentinaFil: Bonfa, Eloisa. Universidade de Sao Paulo; BrasilFil: Soriano, Enrique R.. Instituto Universitario Hospital Italiano de Buenos Aires. Rectorado.; ArgentinaFil: Cardiel, Mario H.. Centro de Investigación Clínica de Morelia; MéxicoFil: Izcovich, Ariel. Hospital Alemán; ArgentinaFil: Popoff, Federico. Hospital Aleman; ArgentinaFil: Criniti, Juan M.. Hospital Alemán; ArgentinaFil: Vásquez, Gloria. Universidad de Antioquia; ColombiaFil: Massardo, Loreto. Universidad San Sebastián; ChileFil: Duarte, Margarita. Hospital de Clínicas; ParaguayFil: Barile Fabris, Leonor A.. Hospital Angeles del Pedregal; MéxicoFil: García, Mercedes A.. Universidad de Buenos Aires. Facultad de Medicina. Hospital de Clínicas General San Martín; ArgentinaFil: Amigo, Mary Carmen. Centro Médico Abc; MéxicoFil: Espada, Graciela. Gobierno de la Ciudad de Buenos Aires. Hospital General de Niños "Ricardo Gutiérrez"; ArgentinaFil: Catoggio, Luis J.. Hospital Italiano. Instituto Universitario. Escuela de Medicina; ArgentinaFil: Sato, Emilia Inoue. Universidade Federal de Sao Paulo; BrasilFil: Levy, Roger A.. Universidade do Estado de Rio do Janeiro; BrasilFil: Acevedo Vásquez, Eduardo M.. Universidad Nacional Mayor de San Marcos; PerúFil: Chacón Díaz, Rosa. Policlínica Méndez Gimón; VenezuelaFil: Galarza Maldonado, Claudio M.. Corporación Médica Monte Sinaí; EcuadorFil: Iglesias Gamarra, Antonio J.. Universidad Nacional de Colombia; ColombiaFil: Molina, José Fernando. Centro Integral de Reumatología; ColombiaFil: Neira, Oscar. Universidad de Chile; ChileFil: Silva, Clóvis A.. Universidade de Sao Paulo; BrasilFil: Vargas Peña, Andrea. Hospital Pasteur Montevideo; UruguayFil: Gómez Puerta, José A.. Hospital Clinic Barcelona; EspañaFil: Scolnik, Marina. Instituto Universitario Hospital Italiano de Buenos Aires. Rectorado.; ArgentinaFil: Pons Estel, Guillermo J.. Centro Regional de Enfermedades Autoinmunes y Reumáticas; Argentina. Hospital Provincial de Rosario; ArgentinaFil: Ugolini Lopes, Michelle R.. Universidade de Sao Paulo; BrasilFil: Savio, Verónica. Instituto Universitario Hospital Italiano de Buenos Aires. Rectorado.; ArgentinaFil: Drenkard, Cristina. University of Emory; Estados UnidosFil: Alvarellos, Alejandro J.. Hospital Privado Universitario de Córdoba; ArgentinaFil: Ugarte Gil, Manuel F.. Universidad Cientifica del Sur; Perú. Hospital Nacional Guillermo Almenara Irigoyen; PerúFil: Babini, Alejandra. Instituto Universitario Hospital Italiano de Buenos Aires. Rectorado.; ArgentinaFil: Cavalcanti, André. Universidade Federal de Pernambuco; BrasilFil: Cardoso Linhares, Fernanda Athayde. Hospital Pasteur Montevideo; UruguayFil: Haye Salinas, Maria Jezabel. Hospital Privado Universitario de Córdoba; ArgentinaFil: Fuentes Silva, Yurilis J.. Universidad de Oriente - Núcleo Bolívar; VenezuelaFil: Montandon De Oliveira E Silva, Ana Carolina. Universidade Federal de Goiás; BrasilFil: Eraso Garnica, Ruth M.. Universidad de Antioquia; ColombiaFil: Herrera Uribe, Sebastián. Hospital General de Medellin Luz Castro de Gutiérrez; ColombiaFil: Gómez Martín, DIana. Instituto Nacional de la Nutrición Salvador Zubiran; MéxicoFil: Robaina Sevrini, Ricardo. Universidad de la República; UruguayFil: Quintana, Rosana M.. Hospital Provincial de Rosario; Argentina. Centro Regional de Enfermedades Autoinmunes y Reumáticas; ArgentinaFil: Gordon, Sergio. Hospital Interzonal General de Agudos Dr Oscar Alende. Unidad de Reumatología y Enfermedades Autoinmunes Sistémicas; ArgentinaFil: Fragoso Loyo, Hilda. Instituto Nacional de la Nutrición Salvador Zubiran; MéxicoFil: Rosario, Violeta. Hospital Docente Padre Billini; República DominicanaFil: Saurit, Verónica. Hospital Privado Universitario de Córdoba; ArgentinaFil: Appenzeller, Simone. Universidade Estadual de Campinas; BrasilFil: Dos Reis Neto, Edgard Torres. Universidade Federal de Sao Paulo; BrasilFil: Cieza, Jorge. Hospital Nacional Edgardo Rebagliati Martins; PerúFil: González Naranjo, Luis A.. Universidad de Antioquia; ColombiaFil: González Bello, Yelitza C.. Ceibac; MéxicoFil: Collado, María Victoria. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Investigaciones Médicas; ArgentinaFil: Sarano, Judith. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Investigaciones Médicas; ArgentinaFil: Retamozo, Maria Soledad. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Córdoba. Instituto de Investigaciones en Ciencias de la Salud. Universidad Nacional de Córdoba. Instituto de Investigaciones en Ciencias de la Salud; ArgentinaFil: Sattler, María E.. Provincia de Buenos Aires. Ministerio de Salud. Hospital Interzonal de Agudos "Eva Perón"; ArgentinaFil: Gamboa Cárdenas, Rocio V.. Hospital Nacional Guillermo Almenara Irigoyen; PerúFil: Cairoli, Ernesto. Universidad de la República; UruguayFil: Conti, Silvana M.. Hospital Provincial de Rosario; ArgentinaFil: Amezcua Guerra, Luis M.. Instituto Nacional de Cardiologia Ignacio Chavez; MéxicoFil: Silveira, Luis H.. Instituto Nacional de Cardiologia Ignacio Chavez; MéxicoFil: Borba, Eduardo F.. Universidade de Sao Paulo; BrasilFil: Pera, Mariana A.. Hospital Interzonal General de Agudos General San Martín; ArgentinaFil: Alba Moreyra, Paula B.. Universidad Nacional de Córdoba. Facultad de Medicina; ArgentinaFil: Arturi, Valeria. Hospital Interzonal General de Agudos General San Martín; ArgentinaFil: Berbotto, Guillermo A.. Provincia de Buenos Aires. Ministerio de Salud. Hospital Interzonal de Agudos "Eva Perón"; ArgentinaFil: Gerling, Cristian. Hospital Interzonal General de Agudos Dr Oscar Alende. Unidad de Reumatología y Enfermedades Autoinmunes Sistémicas; ArgentinaFil: Gobbi, Carla Andrea. Universidad Nacional de Córdoba. Facultad de Medicina; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Gervasoni, Viviana L.. Hospital Provincial de Rosario; ArgentinaFil: Scherbarth, Hugo R.. Hospital Interzonal General de Agudos Dr Oscar Alende. Unidad de Reumatología y Enfermedades Autoinmunes Sistémicas; ArgentinaFil: Brenol, João C. Tavares. Hospital de Clinicas de Porto Alegre; BrasilFil: Cavalcanti, Fernando. Universidade Federal de Pernambuco; BrasilFil: Costallat, Lilian T. Lavras. Universidade Estadual de Campinas; BrasilFil: Da Silva, Nilzio A.. Universidade Federal de Goiás; BrasilFil: Monticielo, Odirlei A.. Hospital de Clinicas de Porto Alegre; BrasilFil: Seguro, Luciana Parente Costa. Universidade de Sao Paulo; BrasilFil: Xavier, Ricardo M.. Hospital de Clinicas de Porto Alegre; BrasilFil: Llanos, Carolina. Universidad Católica de Chile; ChileFil: Montúfar Guardado, Rubén A.. Instituto Salvadoreño de la Seguridad Social; El SalvadorFil: Garcia De La Torre, Ignacio. Hospital General de Occidente; MéxicoFil: Pineda, Carlos. Instituto Nacional de Rehabilitación; MéxicoFil: Portela Hernández, Margarita. Umae Hospital de Especialidades Centro Medico Nacional Siglo Xxi; MéxicoFil: Danza, Alvaro. Hospital Pasteur Montevideo; UruguayFil: Guibert Toledano, Marlene. Medical-surgical Research Center; CubaFil: Reyes, Gil Llerena. Medical-surgical Research Center; CubaFil: Acosta Colman, Maria Isabel. Hospital de Clínicas; ParaguayFil: Aquino, Alicia M.. Hospital de Clínicas; ParaguayFil: Mora Trujillo, Claudia S.. Hospital Nacional Edgardo Rebagliati Martins; PerúFil: Muñoz Louis, Roberto. Hospital Docente Padre Billini; República DominicanaFil: García Valladares, Ignacio. Centro de Estudios de Investigación Básica y Clínica; MéxicoFil: Orozco, María Celeste. Instituto de Rehabilitación Psicofísica; ArgentinaFil: Burgos, Paula I.. Pontificia Universidad Católica de Chile; ChileFil: Betancur, Graciela V.. Instituto de Rehabilitación Psicofísica; ArgentinaFil: Alarcón, Graciela S.. Universidad Peruana Cayetano Heredia; Perú. University of Alabama at Birmingahm; Estados Unido

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Sistemas Modernos de Contabilidad

The book deals with relevant and current issues about accounting systems, methods and records from the second decade of the 20th century. The first knowledge related to the accounting function is reflected in the univocal contribution that the author consumes with the expression to Castilian, with a particular eloquent and subtle style, without departing from scientific technicalities from another continent. This is the first accounting book in Mexico, which translates concepts and technicalities from English (England and the United States of North America) to Spanish without neglecting Mexican business functions and needs. This first contribution focuses its objective on providing knowledge to accounting slang and convergence towards case studies of real companies that started operations in Mexico, as an attempt to compensate the economy weakened by the aftermath of the Mexican revolution. Likewise, the book separates systematization from practicality until it reaches business results for decision-making by future and current accountants of that time, through financial statements that are still in force today. This legacy remains in force subject to global technological changes.El libro trata de temas relevantes y actuales acerca de los sistemas, métodos y registros contables a partir de la segunda década del siglo XX.  Los primeros conocimientos vinculados a la función de la contaduría se ven reflejados en la aportación univoca que el autor consuma con la expresión al castellano, con un estilo particular elocuente y sutil, sin apartarse de los tecnicismos científicos provenientes de otro continente. Este es el primer libro de contabilidad en México, que traduce conceptos y tecnicismos del inglés (Inglaterra y Estados unidos de Norte América) al español sin descuidar las funciones y necesidades empresariales mexicanas. Esta primera aportación, centra su objetivo en proporcionar los conocimientos al argot contable y la convergencia hacia estudios de casos de empresas reales que iniciaban sus operaciones en  México, como intento de resarcir la economía debilitada por las secuelas de la revolución mexicana. Asimismo, el libro separa la sistematización, de la practicidad hasta llegar a los resultados empresariales para la toma de decisiones de los futuros y actuales contadores de aquella época, a través estados financieros hasta hoy vigentes. Este legado permanece vigente a reserva de los cambios tecnológicos globales

Sistemas Modernos de Contabilidad

The book deals with relevant and current issues about accounting systems, methods and records from the second decade of the 20th century. The first knowledge related to the accounting function is reflected in the univocal contribution that the author consumes with the expression to Castilian, with a particular eloquent and subtle style, without departing from scientific technicalities from another continent. This is the first accounting book in Mexico, which translates concepts and technicalities from English (England and the United States of North America) to Spanish without neglecting Mexican business functions and needs. This first contribution focuses its objective on providing knowledge to accounting slang and convergence towards case studies of real companies that started operations in Mexico, as an attempt to compensate the economy weakened by the aftermath of the Mexican revolution. Likewise, the book separates systematization from practicality until it reaches business results for decision-making by future and current accountants of that time, through financial statements that are still in force today. This legacy remains in force subject to global technological changes.El libro trata de temas relevantes y actuales acerca de los sistemas, métodos y registros contables a partir de la segunda década del siglo XX.  Los primeros conocimientos vinculados a la función de la contaduría se ven reflejados en la aportación univoca que el autor consuma con la expresión al castellano, con un estilo particular elocuente y sutil, sin apartarse de los tecnicismos científicos provenientes de otro continente. Este es el primer libro de contabilidad en México, que traduce conceptos y tecnicismos del inglés (Inglaterra y Estados unidos de Norte América) al español sin descuidar las funciones y necesidades empresariales mexicanas. Esta primera aportación, centra su objetivo en proporcionar los conocimientos al argot contable y la convergencia hacia estudios de casos de empresas reales que iniciaban sus operaciones en  México, como intento de resarcir la economía debilitada por las secuelas de la revolución mexicana. Asimismo, el libro separa la sistematización, de la practicidad hasta llegar a los resultados empresariales para la toma de decisiones de los futuros y actuales contadores de aquella época, a través estados financieros hasta hoy vigentes. Este legado permanece vigente a reserva de los cambios tecnológicos globales

Measurement of the Fluctuations in the Number of Muons in Extensive Air Showers with the Pierre Auger Observatory

The successful installation, commissioning, and operation of the Pierre Auger Observatory would not have been possible without the strong commitment and effort from the technical and administrative staff in Malargue. We are very grateful to the following agencies and organizations for financial support: Argentina-Comision Nacional de Energia Atomica, Agencia Nacional de Promocion Cientifica y Tecnologica (ANPCyT), Consejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET), Gobierno de la Provincia de Mendoza, Municipalidad de Malargue, NDM Holdings and Valle Las Lenas; in gratitude for their continuing cooperation over land access; Australia-the Australian Research Council; BrazilConselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq), Financiadora de Estudos e Projetos (FINEP), Fundacao de Amparo a Pesquisa do Estado de Rio de Janeiro (FAPERJ), Sao Paulo Research Foundation (FAPESP) Grants No. 2019/10151-2, No. 2010/07359-6, and No. 1999/05404-3, Ministerio da Ciencia, Tecnologia, Inovacoes e Comunicacoes (MCTIC); Ministry of Education, Youth and Sports of the Czech RepublicGrants No. MSMT CR LTT18004, No. LM2015038, No. LM2018102, No. CZ.02.1.01/0.0/0.0/16_013/0001402, No. CZ.02.1.01/0.0/0.0/18_046/0016010, and No. CZ.02.1.01/0.0/0.0/17_049/0008422; France-Centre de Calcul IN2P3/CNRS, Centre National de la Recherche Scientifique (CNRS), Conseil Regional Ile-de-France, Departement Physique Nucl ' eaire et Corpusculaire (PNC-IN2P3/CNRS), Departement Sciences de l'Univers (SDU-INSU/CNRS), Institut Lagrange de Paris (ILP) Grant No. LABEX ANR-10-LABX-63 within the Investissements d'Avenir Programme Grant No. ANR11-IDEX-0004-02; Germany-Bundesministerium fur Bildung und Forschung (BMBF), Deutsche Forschungsgemeinschaft (DFG), Finanzministerium Baden-Wurttemberg, Helmholtz Alliance for Astroparticle Physics (HAP), Helmholtz-Gemeinschaft Deutscher Forschungszentren (HGF), Ministerium fur Innovation, Wissenschaft und Forschung des Landes Nordrhein-Westfalen, Ministerium fur Wissenschaft, Forschung und Kunst des Landes Baden-Wurttemberg; Italy-Istituto Nazionale di Fisica Nucleare (INFN), Istituto Nazionale di Astrofisica (INAF), Ministero dell'Istruzione, dell'Universita e della Ricerca (MIUR), CETEMPS Center of Excellence, Ministero degli Affari Esteri (MAE); Mexico-Consejo Nacional de Ciencia y Tecnologia (CONACYT) Grant No. 167733, Universidad Nacional Autonoma de Mexico (UNAM), PAPIIT DGAPA-UNAM; The Netherlands-Ministry of Education, Culture and Science, Netherlands Organisation for Scientific Research (NWO), Dutch national e-infrastructure with the support of SURF Cooperative; Poland-Ministry of Science and Higher Education, Grant No. DIR/WK/2018/11, National Science Centre, Grants No. 2013/08/M/ST9/00322, No. 2016/23/B/ST9/01635, and No. HARMONIA 5-2013/10/M/ST9/00062, UMO-2016/22/M/ST9/00198; Portugal -Portuguese national funds and FEDER funds within Programa Operacional Factores de Competitividade through Fundacao para a Ciencia e a Tecnologia (COMPETE); Romania-Romanian Ministry of Education and Research, the Program Nucleu within MCI (PN19150201/16N/2019 and PN19060102), and project PN-III-P1-1.2-PCCDI-2017-0839/19PCCDI/2018 within PNCDI III; Slovenia-Slovenian Research Agency, Grants No. P1-0031, No. P1-0385, No. I00033, No. N1-0111; Spain-Ministerio de Economia, Industria y Competitividad (FPA2017-85114-P and FPA2017-85197-P), Xunta de Galicia (ED431C 2017/07), Junta de Andalucia (SOMM17/6104/UGR), Feder Funds, RENATA Red Nacional Tematica de Astroparticulas (FPA2015-68783-REDT), and Maria de Maeztu Unit of Excellence (MDM-2016-0692); U.S.Department of Energy, Awards No. DE-AC0207CH11359, No. DE-FR02-04ER41300, No. DE-FG0299ER41107, and No. DE-SC0011689, National Science Foundation, Grant No. 0450696, The Grainger Foundation, Marie Curie-IRSES/EPLANET, European Particle Physics Latin American Network, and UNESCO.We present the first measurement of the fluctuations in the number of muons in extensive air showers produced by ultrahigh energy cosmic rays. We find that the measured fluctuations are in good agreement with predictions from air shower simulations. This observation provides new insights into the origin of the previously reported deficit of muons in air shower simulations and constrains models of hadronic interactions at ultrahigh energies. Our measurement is compatible with the muon deficit originating from small deviations in the predictions from hadronic interaction models of particle production that accumulate as the showers develop.Argentina-Comision Nacional de Energia AtomicaANPCyTConsejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET)Gobierno de la Provincia de MendozaMunicipalidad de MalargueNDM HoldingsValle Las LenasAustralian Research CouncilConselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPQ)Fundacao de Apoio a Pesquisa do Distrito Federal (FAPDF)Financiadora de Inovacao e Pesquisa (Finep)Fundacao Carlos Chagas Filho de Amparo a Pesquisa do Estado do Rio De Janeiro (FAPERJ)Fundacao de Amparo a Pesquisa do Estado de Sao Paulo (FAPESP) 2019/10151-2 2010/07359-6 1999/05404-3Ministerio da Ciencia, Tecnologia, Inovacoes e Comunicacoes (MCTIC)Ministry of Education, Youth & Sports - Czech Republic MSMT CR LTT18004 LM2015038 LM2018102 CZ.02.1.01/0.0/0.0/16_013/0001402 CZ.02.1.01/0.0/0.0/18_046/0016010 CZ.02.1.01/0.0/0.0/17_049/0008422France-Centre de Calcul IN2P3/CNRSCentre National de la Recherche Scientifique (CNRS)Region Ile-de-FranceCentre National de la Recherche Scientifique (CNRS)Departement Sciences de l'Univers (SDU-INSU/CNRS)French National Research Agency (ANR) LABEX ANR-10-LABX-63 ANR11-IDEX-0004-02Federal Ministry of Education & Research (BMBF)German Research Foundation (DFG)Finanzministerium Baden-WurttembergHelmholtz Alliance for Astroparticle Physics (HAP)Helmholtz AssociationMinisterium fur Innovation, Wissenschaft und Forschung des Landes Nordrhein-WestfalenMinisterium fur Wissenschaft, Forschung und Kunst des Landes Baden-WurttembergItaly-Istituto Nazionale di Fisica Nucleare (INFN)Istituto Nazionale Astrofisica (INAF)Ministry of Education, Universities and Research (MIUR)CETEMPS Center of ExcellenceMinistry of Foreign Affairs and International Cooperation (Italy)Consejo Nacional de Ciencia y Tecnologia (CONACyT) 167733Universidad Nacional Autonoma de Mexico (UNAM), PAPIIT DGAPA-UNAMNetherlands-Ministry of Education, Culture and ScienceNetherlands Organization for Scientific Research (NWO)Dutch national e-infrastructureSURF CooperativePoland-Ministry of Science and Higher Education DIR/WK/2018/11National Science Centre, Poland 2013/08/M/ST9/00322 2016/23/B/ST9/01635 HARMONIA 5-2013/10/M/ST9/00062 UMO-2016/22/M/ST9/00198Portugal -Portuguese national fundsFEDER funds within Programa Operacional Factores de Competitividade through Fundacao para a Ciencia e a Tecnologia (COMPETE)Romania-Romanian Ministry of Education and Research, the Program Nucleu within MCI PN19150201/16N/2019 PN19060102Romania-Romanian Ministry of Educatio n and Research, the Program Nucleu within PNCDI III PN-III-P1-1.2-PCCDI-2017-0839/19PCCDI/2018Slovenian Research Agency - Slovenia P1-0031 P1-0385 I00033 N1-0111Spain-Ministerio de Economia, Industria y Competitividad FPA2017-85114-P FPA2017-85197-PXunta de Galicia European Commission ED431C 2017/07Junta de Andalucia SOMM17/6104/UGREuropean CommissionRENATA Red Nacional Tematica de Astroparticulas FPA2015-68783-REDTMaria de Maeztu Unit of Excellence MDM-2016-0692United States Department of Energy (DOE) DE-AC0207CH11359 DE-FR02-04ER41300 DE-FG0299ER41107 DE-SC0011689National Science Foundation (NSF) 0450696Grainger FoundationMarie Curie-IRSES/EPLANETEuropean Particle Physics Latin American NetworkUNESC