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Envenomation by reptile venom, particularly from lizards, poses significant health risks and can lead to physiological and cardiovascular changes. The venom of Heloderma horridum horridum, endemic to Colima, Mexico, was tested on Wistar rats. Electrocardiographic (ECG) data were collected pre-treatment and at 5-min intervals for 1 h post-envenomation. A specially designed computational linear regression algorithm (LRA) was used for the segmentation analysis of the ECG data to improve the detection of fiducial points (P, Q, R, S, and T) in ECG waves. Additionally, heart tissue was analyzed for macroscopic and microscopic changes. The results revealed significant electrocardiographic alterations, including pacemaker migration, junctional extrasystoles, and intraventricular conduction aberrations. By applying a linear regression algorithm, the study compensated for noise and anomalies in the isoelectric line in an ECG signal, improving the detection of P and T waves and the QRS complex with an efficiency of 97.5%. Cardiac enzyme evaluation indicated no statistically significant differences between the control and experimental groups. Macroscopic and microscopic examination revealed no apparent signs of damage or inflammatory responses in heart tissues. This study enhances our understanding of the cardiovascular impact of Heloderma venom, suggesting a greater influence on changes in conduction and arrhythmias than on direct cardiac damage to the myocardium.
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Heloderma horridum horridum, a venomous reptile native to America, has a venom with potential applications in treating type II diabetes. In this work, H. h. horridum venom was extracted, lyophilized, and characterized using enzymatic assays for hyaluronidase, phospholipase, and protease. Proteomic analysis of the venom was conducted employing bottom-up/shotgun approaches, SDS-PAGE, high-pH reversed-phase chromatography, and fractionation of tryptic peptides using nano-LC-MS/MS. The proteins found in H. h. horridum venom were reviewed according to the classification of the transcriptome previously reported. The proteomic approach identified 101 enzymes, 36 other proteins, 15 protein inhibitors, 11 host defense proteins, and 1 toxin, including novel venom components such as calcium-binding proteins, phospholipase A2 inhibitors, serpins, cathepsin, subtilases, carboxypeptidase-like, aminopeptidases, glycoside hydrolases, thioredoxin transferases, acid ceramidase-like, enolase, multicopper oxidases, phosphoglucose isomerase (PGI), fructose-1,6-bisphosphatase class 1, pentraxin-related, peptidylglycine α-hydroxylating monooxygenase/peptidyl-hydroxyglycine α-amidating lyase, carbonic anhydrase, acetylcholinesterase, dipeptidylpeptidase, and lysozymes. These findings contribute to understanding the venomous nature of H. h. horridum and highlight its potential as a source of bioactive compounds. Data are available via PRoteomeXchange with the identifier PXD052417.
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Animales Ponzoñosos , Lagartos , Proteómica , Espectrometría de Masas en Tándem , Ponzoñas , Animales , Animales Ponzoñosos/genética , Animales Ponzoñosos/metabolismo , Hialuronoglucosaminidasa/metabolismo , Hialuronoglucosaminidasa/antagonistas & inhibidores , Hialuronoglucosaminidasa/genética , Hypocreales/química , Hypocreales/genética , Lagartos/genética , Lagartos/metabolismo , Proteoma/análisis , Proteómica/métodos , Proteínas de Reptiles/genética , Proteínas de Reptiles/metabolismo , Proteínas de Reptiles/química , Transcriptoma , Ponzoñas/químicaRESUMEN
This study proposes an alternative method using Na2EDTA to neutralize B. alternatus venom and using it as an immunogen from the start of inoculation to minimize side effects and enhance antivenom production. To achieve this, 1.8 mg/mL of B. alternatus venom (B.aV) was treated with Na2EDTA, and any extra chelate was eliminated by filtering the resulting solution through a Sephadex G-25 column. Two groups of BALB/c mice were immunized subcutaneously on days 1, 15 and 30 with B.aV/Na2EDTA (45, 90, 135 µg/mouse) or B.aV (15, 30, 45 µg/mouse), respectively. Both formulations were emulsified with Freund's adjuvant (complete first and incomplete-booster). Blood samples were collected from each mouse on days 14, 29, 41, and 50 post-first immunization, and serum was separated for antibody detection. Animals were then sacrificed and lungs removed for histological analysis (hematoxylin-eosin). Immunoblotting analysis revealed that the sera from mice inoculated with B.aV/Na2EDTA (anti-B.aV/Na2EDTA) recognized the major venom proteins (20-66 kDa) similarly to the sera from mice inoculated with B.aV (anti-B.aV). The enzyme-linked immunosorbent assay results indicated that the anti-B.aV/Na2EDTA had a higher titer (5.76 × 104) than those the anti-B.aV (1.92 × 104). Additionally, sera from animals immunized with B.aV/Na2EDTA significantly neutralized proteolytic, indirect hemolytic and coagulant activity (p < 0.05). Finally, histological examination of the lungs of mice inoculated with B.aV/Na2EDTA showed normal appearance, while animals inoculated with B.aV showed interstitial lung injury (p < 0.05). In conclusion, the B.aV/Na2EDTA formulation, free of excess Na2EDTA, proved to be a promising candidate as an immunogen for antivenom production.
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Bothrops , Venenos de Crotálidos , Ratones , Animales , Antivenenos/farmacología , Ácido Edético/farmacologíaRESUMEN
Centruroides possanii is a recently discovered species of "striped scorpion" found in Mexico. Certain species of Centruroides are known to be toxic to mammals, leading to numerous cases of human intoxications in the country. Venom components are thought to possess therapeutic potential and/or biotechnological applications. Hence, obtaining and analyzing the secretory gland transcriptome and venom proteome of C. possanii is relevant, and that is what is described in this communication. Since this is a newly described species, first, its LD50 to mice was determined and estimated to be 659 ng/g mouse weight. Using RNA extracted from this species and preparing their corresponding cDNA fragments, a transcriptome analysis was obtained on a Genome Analyzer (Illumina) using the 76-base pair-end sequencing protocol. Via high-throughput sequencing, 19,158,736 reads were obtained and ensembled in 835,204 sequences. Of them, 28,399 transcripts were annotated with Pfam. A total of 244 complete transcripts were identified in the transcriptome of C. possanii. Of these, 109 sequences showed identity to toxins that act on ion channels, 47 enzymes, 17 protease inhibitors (PINs), 11 defense peptides (HDPs), and 60 in other components. In addition, a sample of the soluble venom obtained from this scorpion was analyzed using an Orbitrap Velos apparatus, which allowed for identification by liquid chromatography followed by mass spectrometry (LC-MS/MS) of 70 peptides and proteins: 23 toxins, 27 enzymes, 6 PINs, 3 HDPs, and 11 other components. Until now, this work has the highest number of scorpion venom components identified through omics technologies. The main novel findings described here were analyzed in comparison with the known data from the literature, and this process permitted some new insights in this field.
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Escorpiones , Ponzoñas , Humanos , Animales , Ratones , Escorpiones/genética , Cromatografía Liquida , Espectrometría de Masas en Tándem , Inhibidores de Proteasas , MamíferosRESUMEN
Entomopathogenic fungi (EPF) preservation aims to maintain valuable characteristics. Growth, conidiation and genetic stability of eight species of EPF were evaluated in six preservation methods for up to 8.2 years. Cryopreservation at -196 °C, freeze-drying, and ultra-freezing at -70 °C resulted as the best methods for long-term storage.
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Criopreservación , Criopreservación/métodos , Liofilización/métodos , CongelaciónRESUMEN
The rapidly growing field of tissue engineering hopes to soon address the shortage of transplantable tissues, allowing for precise control and fabrication that could be made for each specific patient. The protocols currently in place to print large-scale tissues have yet to address the main challenge of nutritional deficiencies in the central areas of the engineered tissue, causing necrosis deep within and rendering it ineffective. Bioprinted microvasculature has been proposed to encourage angiogenesis and facilitate the mobility of oxygen and nutrients throughout the engineered tissue. An implant made via an inkjet printing process containing human microvascular endothelial cells was placed in both B17-SCID and NSG-SGM3 animal models to determine the rate of angiogenesis and degree of cell survival. The implantable tissues were made using a combination of alginate and gelatin type B; all implants were printed via previously published procedures using a modified HP inkjet printer. Histopathological results show a dramatic increase in the average microvasculature formation for mice that received the printed constructs within the implant area when compared to the manual and control implants, indicating inkjet bioprinting technology can be effectively used for vascularization of engineered tissues.
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Apertura ligamento gástro-cólico, acceso a transcavidad de los epiplones. Descenso ángulo hepato-colónico, maniobra Kocher. Sección de vasos gastroepiplóicos derechos. Sección de antro gástrico. Sección de arteria pilórica y gastroduodenal. Pasaje retropancreático, sección cuello páncreas. Decruzamiento retromesentérico, sección de primera asa. Liberación proceso uncinado, sección vía biliar. Linfadenectomía pedículo hepático. Extracción de pieza. Ascenso de yeyuno vía retromesentérica, confeccionando anastomosis: hepático-yeyuno. Pancreato-yeyunal. Ducto-mucosa, tutorizada a exterior. Apertura mesocolon-transverso, pasaje de yeyuno y sección. Gastro-yeyuno anastomosis, por vía trasmesocolónica. Confeccionando anastomosis al pie en Y de Roux, 60 cm de anastomosis previa. Drenajes sobre anastomosis pancreático-biliar fijándolos a piel.
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Humanos , Masculino , Persona de Mediana Edad , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/métodos , Laparoscopía/métodos , Recursos Audiovisuales , Resultado del Tratamiento , Medios AudiovisualesRESUMEN
ABSTRACT Background: Artificial intelligence (AI) in radiology has improved diagnostic performance and shortened reading times of coronavirus disease 2019 (COVID-19) patients studies. Objectives: The objectives pf the study were to analyze the performance of a chest computed tomography (CT) AI quantitative algorithm for determining the risk of mortality/mechanical ventilation (MV) in hospitalized COVID-19 patients and explore a prognostic multivariate model in a tertiary-care center in Mexico City. Methods: Chest CT images of 166 COVID-19 patients hospitalized from April 1 to 20, 2020, were retrospectively analyzed using AI algorithm software. Data were collected from their medical records. We analyzed the diagnostic yield of the relevant CT variables using the area under the ROC curve (area under the curve [AUC]). Optimal thresholds were obtained using the Youden index. We proposed a predictive logistic model for each outcome based on CT AI measures and predetermined laboratory and clinical characteristics. Results: The highest diagnostic yield of the assessed CT variables for mortality was the percentage of total opacity (threshold >51%; AUC = 0.88, sensitivity = 74%, and specificity = 91%). The AUC of the CT severity score (threshold > 12.5) was 0.88 for MV (sensitivity = 65% and specificity = 92%). The proposed prognostic models include the percentage of opacity and lactate dehydrogenase level for mortality and troponin I and CT severity score for MV requirement. Conclusion: The AI-calculated CT severity score and total opacity percentage showed good diagnostic accuracy for mortality and met MV criteria. The proposed prognostic models using biochemical variables and imaging data measured by AI on chest CT showed good risk classification in our population of hospitalized COVID-19 patients.
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BACKGROUND: Artificial intelligence (AI) in radiology has improved diagnostic performance and shortened reading times of coronavirus disease 2019 (COVID-19) patients' studies. OBJECTIVES: The objectives pf the study were to analyze the performance of a chest computed tomography (CT) AI quantitative algorithm for determining the risk of mortality/mechanical ventilation (MV) in hospitalized COVID-19 patients and explore a prognostic multivariate model in a tertiary-care center in Mexico City. METHODS: Chest CT images of 166 COVID-19 patients hospitalized from April 1 to 20, 2020, were retrospectively analyzed using AI algorithm software. Data were collected from their medical records. We analyzed the diagnostic yield of the relevant CT variables using the area under the ROC curve (area under the curve [AUC]). Optimal thresholds were obtained using the Youden index. We proposed a predictive logistic model for each outcome based on CT AI measures and predetermined laboratory and clinical characteristics. RESULTS: The highest diagnostic yield of the assessed CT variables for mortality was the percentage of total opacity (threshold >51%; AUC = 0.88, sensitivity = 74%, and specificity = 91%). The AUC of the CT severity score (threshold > 12.5) was 0.88 for MV (sensitivity = 65% and specificity = 92%). The proposed prognostic models include the percentage of opacity and lactate dehydrogenase level for mortality and troponin I and CT severity score for MV requirement. CONCLUSION: The AI-calculated CT severity score and total opacity percentage showed good diagnostic accuracy for mortality and met MV criteria. The proposed prognostic models using biochemical variables and imaging data measured by AI on chest CT showed good risk classification in our population of hospitalized COVID-19 patients.
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Lizards of the Helodermatidae (Anguimorpha) family consist of at least two well recognized species: Heloderma horridum horridum and Heloderma suspectum suspectum. They contain specialized glands in their jaws that produce venomous secretions that causes envenoming symptoms to bitten animals. One way to study proteins from such secretions is by RNA-seq; a powerful molecular tool to characterize the transcriptome of such specialized gland, and its protein secretions. The total RNA from venom gland tissues of H. horridum horridum was extracted and a cDNA library was constructed and sequenced. Overall, 114,172 transcripts were found, and 199 were annotated based on sequence similarities to previously described peptides/proteins. Transcripts coding for putative exendins, defensins, natriuretics and serine protease inhibitors were the most highly expressed. Transcripts that code for several putative serine proteases, phospholipases, metalloproteases, lipases, L-amino oxidase and nucleases were also found. Some of the novel identified transcripts were translationally controlled tumor proteins, venom factors, vespryns, waprins, lectins, cystatins and serine protease inhibitors. All these new protein structures may contribute to a better understanding of the venomous secretions of the Helodermatidae family.
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Lagartos/genética , Ponzoñas , Secuencia de Aminoácidos , Animales , Secuencia de Bases , Secuenciación de Nucleótidos de Alto Rendimiento , Lagartos/metabolismo , Péptidos , Fosfolipasas , TranscriptomaRESUMEN
Objetivo. Determinar los conocimientos, actitudes y prácticas en relación al autocuidado en los pacientes con diabetes que asisten al centro integral de salud Nueva Suyapa, Tegucigalpa, Honduras Febrero 2019. Diseño: Estudio CAP, con pacientes que asistieron a consulta. Se elaboró un instrumento que contenía las variables correspondientes para cada objetivo a desarrollar y cuatro acápites I Características Sociodemográficas de los pacientes, II los conocimientos, III las actitudes y IV las prácticas de los pacientes en relación a la diabetes. Resultados: El 88% de los encuestados tiene conocimiento insuficiente sobre la enfermedad, el 58% tienen buena actitud en cuanto al tiempo para hacer ejercicio, el 46% muestra actitud favorable en cuanto al cuidado de los pies, un 50% usa calzado cómodo, pero tienen muy malas prácticas en cuanto al ejercicio ya que el 100% refieren no realizar ninguna actividad física.. Conclusiones: De los 50 participantes la mayoría de ellos tienen buenas prácticas en cuanto al cuidado de sus pies y el corte de sus uñas ya que lo hacen de forma correcta, en cuanto al ejercicio no practican ninguna actividad física, la mayoría realiza tres tiempos de comida y no hacen merienda. La actitud en cuanto al sobrepeso es muy buena, ya que refieren estar dispuestos a mejorar su dieta en caso de tener que bajar de peso aunque reconocen que es difícil comer comida saludable
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Calidad de Vida , Diabetes Mellitus Tipo 2 , Dieta , Actividad Motora , Obesidad , Salud PúblicaRESUMEN
Al insertarse la práctica médica en el complejo sistema de relaciones humanas, es importante que el médico, además de actuar con un elevado profesionalismo científico técnico, tenga en cuenta la esencia del ser humano y sea capaz de comunicarse con seguridad, para curar, rehabilitar y prevenir enfermedades. Los objetivos de la carrera de Medicina, aparecen diseñados en correspondencia con tales exigencias, pero existen insuficiencias teóricas y metodológicas para desarrollar la comunicación de manera intencionada y coherente, desde las actividades que realizan los estudiantes en su formación. Es objetivo de este trabajo, profundizar teóricamente en diversos tópicos sobre el tema de la comunicación médico - paciente poco trabajada desde la perspectiva didáctica, por lo que lo novedoso del estudio está en que se ofrecen pautas didácticas, de cómo trabajar el tema desde el inicio de la formación del médico, con el propósito de prepararlo para su futuro desempeño, aspecto poco trabajado en la literatura médica consultada(AU)
When inserting the medical practice in the complex system of human relations, it is important that the doctor, in addition to acting with a high scientific and technical professionalism, take into account the essence of the human being and be able to communicate with security, to cure, rehabilitate and prevent diseases. The objectives of the Medicine career are designed in correspondence with these requirements, but there are theoretical and methodological inadequacies to develop the communication in an intentional and coherent manner, from the activities carried out by the students in their training. The objective of this work is to deepen theoretically in diverse topics on the subject of medical - patient communication, little worked from the didactic perspective, so the novelty of the study is that didactic guidelines are offered, of how to work the topic from the beginning of the training of the doctor, with the purpose of preparing him for his future performance, aspect little worked in the medical literature consulted(AU)
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Humanos , Masculino , Femenino , Carrera , Correspondencia como Asunto , Guías como Asunto , Comunicación , ProfesionalismoRESUMEN
La transformación del currículo en las carreras universitarias en Ecuador, ha generado una creciente preocupación por el estudio de diferentes aspectos de la comunicación interpersonal en el proceso de enseñanza-aprendizaje. El objetivo del presente trabajo es presentar un sistema de métodos para la comunicación interpersonal en el proceso de enseñanza- aprendizaje. El sistema propuesto avala las posibilidades que ofrecen los métodos problémicos en las diferentes fases del proceso de enseñanza-aprendizaje, lo cual se logra al propiciar el diálogo, el intercambio cognitivo y afectivo entre todos los que participan, comparten y aportan al aprendizaje de otros. El sistema de métodos para la comunicación interpersonal en el proceso de enseñanza- aprendizaje, sugiere un cambio en el rol del profesor y en el modo en que se concibe y desarrolla dicho proceso. Por su naturaleza didáctica, es un sistema que explica la comunicación interpersonal como centro del proceso de enseñanza- aprendizaje.
Curriculum transformation in the university majors in Ecuador has generated a growing concern for studying different aspects of interpersonal communication in the teaching-learning process. This paper is aimed at presenting a system of methods for interpersonal communication in the teaching-learning process. The proposed system supports the possibilities offered by the problem methods at different phases of the teaching-learning process, which is achieved by promoting dialogue, cognitive and affective exchange among all those who participate, share and contribute to the learning of others. The system of methods for interpersonal communication in the teaching-learning process suggests a change in the teacher's role and in the way in which this process is conceived and developed. Due to its didactic nature, it is a system which explains interpersonal communication as the center of the teaching-learning process.
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Chan (Hyptis suaveolens) is a Mesoamerican crop highly appreciated since the pre-Hispanic cultures. Its proteins are a good source of essential amino acids; however, there are no reports on the properties of its individual proteins. In this study, the 11S globulin (Hs11S) was purified and biochemically characterized. The molecular weight of native Hs11S was about 150-300 kDa with isoelectric points of 5.0-5.3, composed by four monomers of 53.5, 52, 51.1 and 49.5 kDa, each formed by one acidic subunit and one basic subunit linked by a disulfide bond. Dynamic light scattering, size exclusion chromatography and native PAGE show that Hs11S is assembled in different oligomeric forms. LC-MS/MS analysis confirmed its identity. Hs11S presents antigenic determinants in common with lupin 11S globulin. Carbohydrate moieties or phosphate groups linked to Hs11S were not detected. This information is very useful in order to exploit and utilize rationally chan 11S globulin in food systems.
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Globulinas/aislamiento & purificación , Hyptis/química , Proteínas de Almacenamiento de Semillas/aislamiento & purificación , Semillas/química , Electroforesis en Gel de Poliacrilamida , Punto Isoeléctrico , Peso Molecular , Espectrometría de Masas en TándemRESUMEN
Se realiza un análisis de los conceptos de adicción e inteligencia emocional. Se enfatiza en la importancia del desarrollo de la inteligencia emocional como herramienta radical en el afrontamiento de situaciones difíciles, al evitar la alternativa rápida y comprometida del consumo de sustancias o adicciones de cualquier tipo. Se concluye que promover la inteligencia emocional desde edades tempranas de la vida es sin duda un factor protector frente a los problemas de adicción.
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Humanos , Masculino , Femenino , Niño , Inteligencia Emocional , Fumar , Literatura de Revisión como AsuntoRESUMEN
Se realiza un análisis de la repercusión del humo de segunda mano en las edades pediátricas. Se describen los principales efectos nocivos del tabaquismo pasivo en la infancia y las enfermedades causadas por su efecto. Se enfatiza en la necesidad de proteger a los pacientes pediátricos de la exposición al humo del cigarro.
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Preescolar , Niño , Niño , Preescolar , Contaminación por Humo de Tabaco/efectos adversos , Literatura de Revisión como AsuntoRESUMEN
Papaya (Carica papaya L.) is a climacteric fruit susceptible to postharvest losses due to the ethylene-induced ripening. The inhibitor of ethylene action, 1-methylcyclopropene (1-MCP), has been used worldwide as a safe postharvest non-toxic agent, but the physiological and biochemical modifications induced by 1-MCP are not well understood. Using the 2-DE analysis, we report the changes in the protein profiles after 6 and 18 days of postharvest and the effect of the effect of 1-MCP treatment on fruits. Twenty seven protein spots showing differences in abundance during ripening were successfully identified by nano-LC-ESI/MS/MS. Some spots corresponded to the cell wall degrading enzymes related to fruit ripening; others were involved in oxidative damage protection, protein folding, and cell growth and survival that were induced by 1-MCP. This is the first proteomic report analyzing the effect of 1-MCP in papaya ripening. The present data will help to shed light on papaya fruit ripening process.
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Carica/metabolismo , Ciclopropanos/farmacología , Frutas/metabolismo , Proteínas de Plantas/metabolismo , Proteoma/metabolismo , Proteómica/métodos , Factores de TiempoRESUMEN
Cutaneous larva migrans (CLM) represents the most common tropically acquired dermatosis. CLM is caused by infection with hookworm larvae in tropical and sub-tropical areas, and people who have a history of foreign travel and of walking barefoot on sandy soil or beaches are at a high risk of getting infected with it. The diagnosis is usually made on the basis of the typical appearance of the lesion, intense itching and history of foreign travel. CLM is a common parasitic skin disease that can be easily prevented by wearing 'protective' footwear. A case of CLM is described in this article.
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Larva Migrans , Adulto , Albendazol/uso terapéutico , Antinematodos/uso terapéutico , Argentina , Brasil , Femenino , Humanos , ViajeRESUMEN
El quiste dentígero es una variedad quística de los maxilares que requiere de un diagnóstico temprano por la potencialidad que tiene de evolucionar hacia una patología tumoral y provocar deformidad facial. Se presenta el caso de un niño de 12 años de edad que acude a la consulta de cirugía máxilofacial por presentar un aumento de volumen en el paladar con características inflamatorias que involucraban otras zonas faciales. Después de realizar exámenes de laboratorio y radiográficos, se lleva al salón de operaciones para realizar la extracción de ambos caninos superiores retenidos en posición vertical por el paladar, enuclear el área radiolúcida visible en las radiografías y realizar examen histopatológico. El informe del departamento de Anatomía Patológica corrobora el diagnóstico presuntivo de quiste Dentígero en ambos caninos superiores. La evolución del paciente fue satisfactoria y desaparecieron los síntomas preoperatorios.
The dentigerous cyst is a quistical variety of maxillaries that requires an early diagnosis by the potentiality that it has to evolve towards a tumoral pathology and to bring about face deformity. The case of a boy of 12 years of age that goes to the maxilofacial doctor´s office, who had an increase of volume in the palate with inflammatory characteristics that involved other face zones, is presented After carring out the x-ray and laboratory exams, the extraction of both upper canines, retained on vertical position by the palate, is done in order to enuclear the visible radiolucent area in the x-rays and carry out the histopathologic examination. The report of the Department of Anatomical Pathology corroborates the presuntive diagnosis of Dentigerous cyst in both upper canines. The evolution of the patient was satisfactory and the preoperative symptoms disappeared.
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Humanos , Niño , Quiste Dentígero/cirugía , Quiste Dentígero/patologíaRESUMEN
Se realiza un bosquejo histórico de los orígenes de la Ética, la Ética Médica y los principios que rigen la Bioética. Se realiza un análisis de la relevancia del conocimiento que sobre el consentimiento informado debe tener el personal médico y los pacientes teniendo en cuenta la aplicación consecuente de los principios de la bioética: la autonomía , la beneficiencia y no la maleficiencia y la justicia en aras de un mejor desempeño en el ejercicio de la práctica médica hacia una excelencia en el campo de las Ciencias Médicas. Concluimos que se hace necesario que nuestros médicos dominen el consentimiento informado como elemento vital para garantizar la excelencia en los servicios médicos como aspira nuestro sistema de salud.