[Septic shock originating from a pulmonary focus caused by Pasteurella multocida. Report of one case]. / Shock séptico de foco respiratorio por Pasteurella multocida en un paciente inmunocompetente. Caso Clínico.

Pasteurella multocida is a gram-negative coccobacillus bacterium found as a commensal in the oropharynx of domestic animals such as cats and dogs and some farm animals. Soft tissue infections and occasionally bacteremia in immunocompromised patients with direct contact with animals are described. We report a 61 year old male with a history of scratches and close contact with domestic cats, with a septic shock originating from a pulmonary focus, requiring mechanical ventilation and vasopressors. Blood cultures disclosed the presence of Pasteurella multocida. He responded successfully to antimicrobials.

Effects of changes in trunk inclination on ventilatory efficiency in ARDS patients: quasi-experimental study.

BACKGROUND: Trunk inclination from semirecumbent head-upright to supine-flat positioning reduces driving pressure and increases respiratory system compliance in patients with acute respiratory distress syndrome (ARDS). These effects are associated with an improved ventilatory ratio and reduction in the partial pressure of carbon dioxide (PaCO2). However, these physiological effects have not been completely studied, and their mechanisms have not yet been elucidated. Therefore, this study aimed to evaluate the effects of a change in trunk inclination from semirecumbent (45°) to supine-flat (10°) on physiological dead space and ventilation distribution in different lung regions. RESULTS: Twenty-two ARDS patients on pressure-controlled ventilation underwent three 60-min steps in which trunk inclination was changed from 45° (baseline) to 10° (intervention) and back to 45° (control) in the last step. Tunk inclination from a semirecumbent (45°) to a supine-flat (10°) position resulted in a higher tidal volume [371 (± 76) vs. 433 (± 84) mL (P < 0.001)] and respiratory system compliance [34 (± 10) to 41 (± 12) mL/cmH2O (P < 0.001)]. The CO2 exhaled per minute improved from 191 mL/min (± 34) to 227 mL/min (± 38) (P < 0.001). Accordingly, Bohr's dead space ratio decreased from 0.49 (± 0.07) to 0.41 (± 0.06) (p < 0.001), and PaCO2 decreased from 43 (± 5) to 36 (± 4) mmHg (p < 0.001). In addition, the impedance ratio, which divides the ventilation activity of the ventral region by the dorsal region ventilation activity in tidal images, dropped from 1.27 (0.83-1.78) to 0.86 (0.51-1.33) (p < 0.001). These results, calculated from functional EIT images, indicated further ventilation activity in the dorsal lung regions. These effects rapidly reversed once the patient was repositioned at 45°. CONCLUSIONS: A change in trunk inclination from a semirecumbent (45 degrees) to a supine-flat position (10 degrees) improved Bohr's dead space ratio and reduced PaCO2 in patients with ARDS. This effect is associated with an increase in tidal volume and respiratory system compliance, along with further favourable impedance ventilation distribution toward the dorsal lung regions. This study highlights the importance of considering trunk inclination as a modifiable determinant of physiological parameters. The angle of trunk inclination is essential information that must be reported in ARDS patients.

Shock séptico de foco respiratorio por Pasteurella multocida en un paciente inmunocompetente. Caso Clínico / Septic shock originating from a pulmonary focus caused by Pasteurella multocida. Report of one case

Pasteurella multocida is a gram-negative coccobacillus bacterium found as a commensal in the oropharynx of domestic animals such as cats and dogs and some farm animals. Soft tissue infections and occasionally bacteremia in immunocompromised patients with direct contact with animals are described. We report a 61 year old male with a history of scratches and close contact with domestic cats, with a septic shock originating from a pulmonary focus, requiring mechanical ventilation and vasopressors. Blood cultures disclosed the presence of Pasteurella multocida. He responded successfully to antimicrobials.

Hacia un modelo de atención en salud para el siglo XXI: breve historia del modelo de atención integrada en Chile / Towards a Health Care Model for the 21st Century: a brief history of the integrated care model in Chile

El desarrollo y organización del sistema sanitario en Chile tuvo importantes cambios durante la segunda mitad del siglo pasado, los que permitieron al país mejorar sustantivamente algunos índices de salud poblacional. Por otra parte, tanto el cambio de paradigma biomédico que surgió en el mundo durante las últimas décadas del siglo XX y que se orientaba hacia un modelo biopsicosocial de salud, como la aparición del concepto de Atención Primaria de Salud (APS) como una estrategia de intervención social, se sumaron al cambio en el perfil epidemiológico y demográfico del país y a las expectativas de la población, para alzarse todos ellos como factores catalizadores de un nuevo cambio en la forma de organizar la atención de salud en Chile. Esto generó un espacio para el desarrollo y fortalecimiento del nivel primario de atención de salud y de la medicina ambulatoria, lo que impulsó también la aparición de una nueva generación de especialistas que fueran capaces de dar solución a la gran mayoría de los problemas de las personas y de las comunidades, los médicos especialistas en Medicina Familiar y Comunitaria. Esta nueva forma de organización sanitaria, actualmente vigente en Chile, y que se enmarca dentro del Modelo de Atención Integral de Salud iniciado a comienzos del siglo XXI, está basado en un sistema de salud sustentado en el modelo biopsicosocial y en la APS; y su eje primordial son las personas, las familias y las comunidades.

The development and organization of the health system in Chile underwent important changes during the second half of the last century that allowed the country to substantially improve some population health indices. On the other hand, both the change in the biomedical paradigm that emerged in the world during the last decades of the 20th century and which was oriented towards a biopsychosocial model of health, as well as the appearance of the concept of Primary Health Care as a social intervention strategy, they added to the change in the epidemiological and demographic profile of the country and the expectations of the population, all of them rising as catalysts for a new change in the way of organizing health care in Chile. This created a space for the development and strengthening of the primary level of health care and outpatient medicine, which also promoted the emergence of a new generation of specialists who were capable of solving the vast majority of people's problems. and from the communities, specialists in Family and Community Medicine. This new form of health organization, currently in force in Chile, and which is part of the Comprehensive Health Care Model initiated at the beginning of the 21st century, is based on a health system based on the biopsychosocial model and PHC; and its main axis are people, families and communities.

Sistema hospitalario en situación de crisis: implementación de sistema de comando de incidentes para enfrentar pandemia SARS-CoV-2 en Clínica Las Condes, Chile / Implementation of incident command system to deal with SARS-CoV-2 pandemic in Clínica Las Condes, Chile

La pandemia en Chile generó un desafío de modernización y gestión de los Cuidados Intensivos, haciendo necesario que las unidades de pacientes críticos realizaran un aumento de su capacidad hospitalaria, lo que requiere preparar una infraestructura, un equipamiento mínimo, protocolos y un equipo humano preparado y alineado, para garantizar la seguridad y calidad de atención a los pacientes. Una forma de lograrlo es la incorporación de la estrategia militar de Sistema de Comando de Incidentes, utilizado para enfrentar distintos tipos de desastres, con una estructura modular de comando y sus seccionales de trabajo, con diferentes equipos y líderes para hacer frentes a los variados desafíos. El objetivo de este artículo es describir la instauración del sistema de comando de incidentes en un hospital privado, detallando su conformación y los resultados logrados.

The pandemic in Chile has been a real challenge in terms of modernization and management of intensive care. Critical care units have been forced to increase their hospital capacity in terms of infrastructure, equipment, protocols and human team, while guaranteeing safety and high-quality patient care.One approach to achieve this objective is to develop the army strategy called incident command system that has been used to face different types of disaster. A modular command structure is developed based on the creation of teams each lead by an expert in different areas in order to cope with a variety of upcoming challenges.The objective of this article is to describe the setting up of a successful incident command system in a private hospital, detailing its formation and results obtained.

Terapia continua intra-arterial selectiva con nimodipino para el tratamiento del vasoespasmo refractario en hemorragia subaracnoidea aneurismática: caso clínico / Continuous intra arterial nimodipine for vasospasm secondary to subarachnoid hemorrhage: report of one case

We report a 39-year-old male with an aneurysmal subarachnoid hemorrhage without hydrocephalus, in whom a right choroidal aneurysm was early excluded by endovascular coil insertion. Intracranial pressure (PIC) and cerebral oxygenation (PtiO2) sensors for neuromonitoring were installed due to a persistent comatose state. From the 3rd day, neuromonitoring became altered. CT angiography and cerebral angiography showed severe proximal and distal vasospasm (VE) of the middle (ACM) and anterior (ACA) right cerebral arteries. VE was treated with angioplasty and intravenous nimodipine. Forty eight hours later, despite hemodynamic maximization, neuromonitoring became altered again, mainly explained by a decrease in PtiO2 below 15 mmHg. A severe VE in ACM and right ACA was confirmed by angiography. Given the presence of an early and recurrent VE, which was associated with a decrease in cerebral oxygenation, internal carotid micro-catheters for continuous nimodipine infusion were installed. This therapy maintained a normal neuromonitoring for 15 days. During this period, attempts were done to decrease or discontinue the infusion, but the patient presented parallel falls of cerebral oxygenation or decreased cerebral perfusion observed with perfusion CT, interpreted as persistent VE. Finally, the infusion was stopped at day 15 without significant complication. We conclude that intra-arterial nimodipine continuous infusion in refractory VE can be useful and safe in selected patients. Multimodal neuromonitoring is essential.

[Continuous intra arterial nimodipine for vasospasm secondary to subarachnoid hemorrhage. Report of one case]. / Terapia continua intra-arterial selectiva con nimodipino para el tratamiento del vasoespasmo refractario en hemorragia subaracnoidea aneurismática. Caso clínico.

We report a 39-year-old male with an aneurysmal subarachnoid hemorrhage without hydrocephalus, in whom a right choroidal aneurysm was early excluded by endovascular coil insertion. Intracranial pressure (PIC) and cerebral oxygenation (PtiO2) sensors for neuromonitoring were installed due to a persistent comatose state. From the 3rd day, neuromonitoring became altered. CT angiography and cerebral angiography showed severe proximal and distal vasospasm (VE) of the middle (ACM) and anterior (ACA) right cerebral arteries. VE was treated with angioplasty and intravenous nimodipine. Forty eight hours later, despite hemodynamic maximization, neuromonitoring became altered again, mainly explained by a decrease in PtiO2 below 15 mmHg. A severe VE in ACM and right ACA was confirmed by angiography. Given the presence of an early and recurrent VE, which was associated with a decrease in cerebral oxygenation, internal carotid micro-catheters for continuous nimodipine infusion were installed. This therapy maintained a normal neuromonitoring for 15 days. During this period, attempts were done to decrease or discontinue the infusion, but the patient presented parallel falls of cerebral oxygenation or decreased cerebral perfusion observed with perfusion CT, interpreted as persistent VE. Finally, the infusion was stopped at day 15 without significant complication. We conclude that intra-arterial nimodipine continuous infusion in refractory VE can be useful and safe in selected patients. Multimodal neuromonitoring is essential.

[Metformin-associated lactic acidosis. Report of one case]. / Acidosis láctica asociada a metformina. Caso clínico.

Metformin-associated lactic acidosis is a severe and infrequent adverse event. Early diagnosis is essential to start an early treatment, which often has favorable results. We report a 56 years old non-insulin-requiring type 2 diabetic female who developed a severe metabolic acidosis associated with metformin in relation to an acute renal failure secondary to infectious diarrhea. Early treatment with bicarbonate and continuous hemofiltration allowed a quick improvement of the patient. Metformin-associated lactic acidosis has an elevated mortality (50-80%) and has a specific and effective treatment. Therefore, the condition must be born in mind.

Acidosis láctica asociada a metformina: caso clínico / Metformin-associated lactic acidosis: report of one case

Metformin-associated lactic acidosis is a severe and infrequent adverse event. Early diagnosis is essential to start an early treatment, which often has favorable results. We report a 56 years old non-insulin-requiring type 2 diabetic female who developed a severe metabolic acidosis associated with metformin in relation to an acute renal failure secondary to infectious diarrhea. Early treatment with bicarbonate and continuous hemofiltration allowed a quick improvement of the patient. Metformin-associated lactic acidosis has an elevated mortality (50-80%) and has a specific and effective treatment. Therefore, the condition must be born in mind.

[Acute small bowel diverticulitis in a patient with crohn’s disease]. / Diverticulitis aguda de intestino delgado en un paciente con enfermedad de Crohn: Report of one case.

Diverticular disease of the small intestine is rare, especially when it is located in the jejunum. It is generally asymptomatic, but in some patients it may have complications such as acute diverticulitis with peritonitis, gastrointestinal bleeding or obstruction. In such cases, the recommended treatment is surgery. We report a 77-year-old patient with ileal Crohn’s disease with a long-standing inflammatory phenotype, who developed acute diverticulitis of the jejunum presenting a severe septic shock and secondary multiple-organ failure. It resolved with medical treatment and prolonged antibiotic therapy.

Diverticulitis aguda de intestino delgado en un paciente con enfermedad de Crohn: Report of one case / Acute small bowel diverticulitis in a patient with crohn’s disease

Diverticular disease of the small intestine is rare, especially when it is located in the jejunum. It is generally asymptomatic, but in some patients it may have complications such as acute diverticulitis with peritonitis, gastrointestinal bleeding or obstruction. In such cases, the recommended treatment is surgery. We report a 77-year-old patient with ileal Crohn’s disease with a long-standing inflammatory phenotype, who developed acute diverticulitis of the jejunum presenting a severe septic shock and secondary multiple-organ failure. It resolved with medical treatment and prolonged antibiotic therapy.

Análisis de sensibilidad del nivel tecnológico adoptado en fincas ganaderas de doble propósito del Estado Zulia, Venezuela / Sensitivity analysis of the technological level adopted in the dual purpose cattle farms located in the Zulia State, Venezuela

El objetivo de esta investigación fue simular con base en los factores determinantes del nivel tecnológico en fincas ganaderas de doble propósito, la probabilidad de que una finca o productor pertenezca a un grupo de fincas con alto nivel de tecnología, de acuerdo a escenarios distintos a los que originalmente posee, creados por la combinación de los factores determinantes. Estos factores resultaron del ajuste de un modelo Probit Ordenado sobre una muestra de 102 fincas localizadas en los municipios Jesús Enrique Lossada, La Cañada de Urdaneta y Rosario de Perijá, del estado Zulia, Venezuela, previamente estratificada en tres grupos tecnológicos: Bajo (GT1), Medio (GT2) y Alto (GT3), utilizando el algoritmo K-medias. Los factores determinantes: localización geográfica de la finca, nivel educativo del productor, frecuencia de la asistencia técnica y el tamaño de la finca fueron utilizados para evaluar su efecto sobre la probabilidad, producto del cambio de las condiciones originales de la finca, la cual se interpreta como sensibilidad. De los resultados obtenidos se desprende que, existe una relación positiva entre el tamaño de la finca, la educación del productor, localidad geográfica, la frecuencia con que es utilizada la asistencia técnica, y el nivel de tecnología existente en la finca. Se puede inferir que un productor con un nivel educativo universitario que posea una finca con más de 200 unidades animales, que ésta se encuentre localizada en la zona de Rosario de Perijá, y que además de ello haga uso de la asistencia técnica como parte del manejo de su finca, presenta una alta probabilidad de que este productor tienda a ser más innovador y alcance un nivel tecnológico más alto que el GT1.

The objective of this research was to simulate the probability of the farmer of belonging to a specific technological level according to the presence of the determinant factors in scenarios created different from original conditions. These factors were obtained of applying the Ordered Probit model on a sample of 102 farms, located in Jesus Enrique Lossada, La Cañada de Urdaneta y Rosario de Perijá Municipalities of the Zulia State, Venezuela. The sample was previously stratified in three technological groups: Low (TG1), Middle (TG2) and High (TG3) by the K-means algorithm. The geographic locations of the farm, educative level of the farmer and farm size resulted to be the determinant factors. These factors were utilized to evaluate their effect on the probability due to the changes of original conditions of the farm. These changes in the probability are called sensitivity. The results showed that there is a positive relationship between the determinant factors and technological level of the farm. Therefore, a farmer with university degree, his or her farm is located in Rosario de Perijá with more than 200 animal units. In addition, the farmer utilizes the frequently technical assistance; it is much more probably that this farmer tends more innovated and reaches a higher technological level than the TG1.

Factores que influyen sobre el nivel tecnológico presente en las fincas ganaderas de doble propósito localizadas en el estado Zulia Venezuela / Influence factors on the current technological level in the dual-purpose cattle farms located in the state of Zulia Venezuela

En Venezuela, varios estudios se han realizado para caracterizar las fincas ganaderas de acuerdo al manejo de la finca y a la funcionalidad y desempeño tecnológico, pero hasta la fecha son muy pocos los estudios que permiten identificar los factores que inciden para que un productor utilice determinadas prácticas tecnológicas dentro de las fincas y alcance un nivel tecnológico diferente de otro productor de su localidad. Por esta razón, el objetivo de esta investigación fue identificar y cuantificar los factores que tienen un efecto sobre el nivel tecnológico en las fincas ganaderas ubicadas en las zonas Noroeste y de Perijá del estado Zulia. Para ello se utilizó una muestra de 102 fincas previamente estratificada usando el algoritmo K-medias, resultando tres grupos tecnológicos: Bajo (GT0), Medio (GT1) y Alto (GT2). Posteriormente se utilizó un modelo Probit Ordenado con la finalidad de determinar los factores que inciden sobre el nivel tecnológico de las fincas ganaderas. Cinco factores resultaron determinantes: Zona, nivel educativo, frecuencia de visita del productor a la finca, asistencia técnica y tamaño de la finca. El modelo permite concluir que un productor con un nivel educativo universitario que posea una finca de gran tamaño que se encuentre localizada en la zona de Perijá y además visita la finca con frecuencia y hace uso de la asistencia técnica, tiene una alta probabilidad de pertenecer a otro grupo diferente al GT0.

In Venezuela, several studies have been made to characterize the cattle farmers according to farm management and technological performance. However, for the date of this research, there were very few studies related to the determinant factors that influence on farmer decision for applying some technological practice or reaching a technological level different from other farmer, located in the same area. For this reason, the objective of this research was to identify and quantify the factors that have an effect on technological level of cattle farms loatedin Northwestern and Perija zones of the Zulia State. In a sample of 102 farms previously stratified using K-means algorithm, resulting three technological groups: Low (TG0), Middle (TG1) and High (TG2). Later, an Ordered Probit model was applied in order to determine the factors that affect on technological levels of the cattlefarms. Five factors resulted determinant: Zone, education level, frequency of visit of producers to own farms, technical assistance and farm size. The model allows concluding that a farmer with a large farm located in Perijá, having a university degree, applying technical assistance and visiting his or her farm frequently, has a high probability to belong to another group different from TG0.

Relación entre el nivel de tecnología y los índices de productividad en fincas ganaderas de doble propósito localizadas en la cuenca del lago de Maracaibo / Relationship between level of technology and productivity indices of dual-purpose cattle Ffrms located on the Maracaibo lake basin

Con la finalidad de estudiar la relación que existe entre el nivel tecnológico y los índices de productividad de las fincas ganaderas de doble propósito, localizadas en los municipios Jesús Enrique Lossada, La Cañada de Urdaneta y Rosario de Perijá, se seleccionaron 102 fincas mediante un muestreo aleatorio estratificado con afijación proporcional y el algoritmo K-medias para la identificación de los grupos. Resultando tres grupos tecnológicos identificados como bajo (GT1), medio (GT2) y alto (GT3), Las medias de las productividades parciales entre los diferentes grupos fueron comparadas mediante un análisis de varianza. Posteriormente, con la prueba de Duncan se compararon las productividades parciales de los grupos. El GT3 mostró mayor productividad parcial en varios índices pero sólo en litros leche por vaca total y por mano de obra fueron significativas (P<0,05), asimismo, los indicadores económicos ingreso por vaca total, ingreso total, ganancia neta y margen bruto, resultaron estadísticamente diferente a GT2 y a GT1, Esto permite concluir que el manejo realizado en las fincas del GT3 se refleja en una mayor productividad del rebaño y de la mano de obra, con una menor relación de costo ingreso. Existe una relación directa entre el nivel tecnológico y los indicadores económicos, la ganancia neta y el margen bruto se incrementan a medida que se asciende dentro de los GTs.

In order to study the relationship between the levels of technology and productivity indicators of dual-purpose cattle farms located in the Jesus E. Lossada, La Cañada de Urdaneta y Rosario de Perijá Municipalities, 102 farms were selected by random sampling and K-mean algorithm to create the technological groups. Three technological groups (TGs) were identified: low (TG1), middle (TG2) and high (TG3). Later, the partial productivity means of different groups were compared by variance analysis and the Duncan test was utilized to evaluate the differences among the means. The TG3 showed high partial productivity in several indicators but only milk liters by total-cow and by labor productivity were statistically significant (P<0.05). Also, economical indicators such as income by total-cow, total income, profit and gross profit resulted statistically different from TG2 and TG1. These results allow concluding that TG3 showed a higher herd and labor productivity and lower cost-income relationship due to differences in the farm management of TG3 with respect to other groups. There is a straightforward relationship among technological levels and economical indicators. Profit and gross profit increases as the farm move into higher technological level.

La inseminación artificial y su efecto sobre los índices de productividad parcial en fincas ganaderas de doble propósito / The artificial insemination and its effect on partial productivity index of dual-purpose cattle farms

Los objetivos de este estudio fueron identificar y cuantificar los factores que influyen en la adopción de la inseminación artificial (IA), y evaluar el efecto de utilizar la IA sobre los índices de productividad parcial en el sistema de ganadería de doble propósito localizados en el estado Zulia, Venezuela. Para ello se utilizó un modelo Logit, resultando como significativas en cuanto a la adopción de la IA, las variables: nivel de instrucción del productor, tamaño de la finca, localización de la finca y permanencia del productor en la unidad de producción. Con relación a los índices de productividad parcial, la IA sólo tuvo efecto significativo cobre productividad por animal.

The objectives of this study were to identify and quantify the determinants of artificial insemination (AI) and to evaluate the effect of AI on the partial productivity indices of dual-purpose cattle farms located in Zulia State, Venezuela. A Logit model was used, resulting as the explanatory variables of the use of AI: degree education of farmer, size of farm, geographic location, and frequency of visit of producers to own farms. Regarding to partial productivity indices, the AI only had effect on animal productivity.

Factores que determinan la selección del lugar de compra de carne de res en Maracaibo Venezuela / Factors that determine the selection of the beef purchase place in Maracaibo Venezuela

Un modelo Logit fue especificado para evaluar los factores de decisión del lugar de compra de carne de res por los consumidores. Considerándose como población del estudio a los habitantes del municipio Maracaibo, las 554 carnicerías y los 24 supermercados existentes; se determinó una muestra de 110 carnicerías aleatoriamente por selección simple, y para los supermercados fue del tipo censal. Se aplicó un muestreo bietápico de 3 consumidores por carnicería y de 10 por supermercado para una muestra total de 570 habitantes. Los resultados indican que el ingreso familiar, el tipo de trabajo, la forma de pago, el número de miembros del hogar y la razón de compra son las variables significativas que explican la probabilidad de que un consumidor compre carne de res en un supermercado.

A Logit model was specified to evaluate the decision factors of beef purchase place by the consumers. The study population was the inhabitants of Maracaibo County, the 554 meat markets and the 24 existing supermarkets. A random sample of 110 meat markets was selected, and the sample for the supermarkets consisted of the census. A two-stage sampling was used surveying 3 consumers per meat market and of 10 per supermarket for a total sample of 570 inhabitants. Results indicate that the family income, the job type, the form of payment, the household size and the reason for purchase are the significant variables that explain the probability that a consumer buy beef in a supermarket.

Seroprevalencia de la infección por virus Delta en un grupo de pacientes AgsHB positivo de la ciudad de Maracaibo / Seroprevalence of Delta infection in a group of patients HBsAg positive sera in Maracaibo city

Con el propósito de aportar información preliminar acerca de la penentración de la infección Delta o la Seroprevalencia de la Infección Delta en nuestra población, fueron estudiados para antidelta los sueros de 40 pacientes AgsHB positivos. De éstos, 20 eran pacientes completamente asintomáticos y 20 eran pacientes sintomáticos. De los 20 pacientes asintomáticos, en 3 se determinaron factores de riesgo; 1 era homosexual, 1 era hemodializado por IRC y 1 era enfermera de la Unidad de Diálisis. Ninguno de los pacientes asintomáticos fue positivo para Delta. De los 20 pacientes sintomáticos, uno fue positivo para Delta, lo cual representó una Seroprevalencia del 5%. En este paciente no se determinaron factores de riesgo, pero es importante reslatar que se trataba de un paciente que aun cuando era procedente de la ciudad, era de raza indígena y natural del Distrito Perijá donde se han detectado foco endémicos. Estos resultaos parecen apoyar el hecho de que la infección está restringida a ciertos grupos raciales, los cuales sin embargo parecen haber rebasado los limites geográficos de las áreas donde hasta ahora parecían estar limitados. Además de lo anterior, la utilización del Antidelta como único marcador serológico (lo cual puede subestimar la prevalencia de la infeccion sobre todo en pacientes con hepatitis aguda que son la mayoría de los pacientes sintomáticos), nos aconseja no infravalorar el papel del agente Delta en la génesis de las hepatopatías en nuestro medio, así como su futuro comportamiento epidemiológico