Colombian Consensus on the Treatment of Placenta Accreta Spectrum (PAS) / Consenso Colombiano de Tratamiento del Espectro de Acretismo Placentario (EAP)

Introduction: Placenta accreta spectrum (PAS) is a condition associated with massive postpartum bleeding and maternal mortality. Management guidelines published in high income countries recommend the participation of interdisciplinary teams in hospitals with sufficient resources for performing complex procedures. However, some of the recommendations contained in those guidelines are difficult to implement in low and medium income countries. Objectives: The aim of this consensus is to draft general recommendations for the treatment of PAS in Colombia. Materials and methods: Twenty-three panelists took part in the consensus with their answers to 31 questions related to the treatment of PAS. The panelists were selected based on participation in two surveys designed to determine the resolution capabilities of national and regional hospitals. The modified Delphi methodology was used, introducing two successive discussion rounds. The opinions of the participants, with a consensus of more than 80%, as well as implementation barriers and facilitators, were taken into consideration in order to issue the recommendations. Results: The consensus draftedfive recommendations, integrating the answers of the panelists. Recommendation 1. Primary care institutions must undertake active search of PAS in patients with risk factors: placenta praevia and history of myomectomy or previous cesarean section. In case of ultrasound signs suggesting PAS, patients must be immediately referred, without a minimum gestational age, to hospitals recognized as referral centers. Online communication and care modalities may facilitate the interaction between primary care institutions and referral centers for PAS. The risks and benefits of telemedicine modalities must be weighed. Recommendation 2. Referral hospitals for PAS need to be defined in each region of Colombia, ensuring coverage throughout the national territory. It is advisable to concentrate the flow of patients affected by this condition in a few hospitals with surgical teams specifically trained in PAS, availability of specialized resources, and institutional efforts at improving quality of care with the aim of achieving better health outcomes in pregnant women with this condition. To achieve this goal, participants recommend that healthcare regulatory agencies at a national and regional level should oversee the process of referral for these patients, expediting administrative pathways in those cases in which there is no prior agreement between the insurer and the selected hospital or clinic. Recommendation 3. Referral centers for patients with PAS are urged to build teams consisting of a fixed group of specialists (obstetricians, urologists, general surgeons, interventional radiologists) entrusted with the care of all PAS cases. It is advisable for these interdisciplinary teams to use the "intervention bundle" model as a guidance for building PAS referral centers. This model comprises the following activities: service preparedness, disease prevention and identification, response to the occurrence of the disease, and debriefing after every event. Telemedicine facilitates PAS treatment and should be taken into consideration by interdisciplinary teams caring for this disease. Recommendation 4. Obstetrics residents must be instructed in the performance of maneuvers that are useful for the prevention and treatment of massive intraoperative bleeding due to placenta praevia and PAS, including manual aortic compression, uterine tourniquet, pelvic packing, retrovesical bypass, and Ward maneuver. Specialization Obstetrics and Gynecology programs in Colombia must include the basic concepts of the diagnosis and treatment of PAS. Referral centers for PAS must offer online and in-person training programs for professionals interested in improving their competencies in PAS. Moreover, they must offer permanent remote support (telemedicine) to other hospitals in their region for patients with this condition. Recommendation 5. Patients suspected of having PAS and placenta praevia based on imaging, with no evidence of active vaginal bleeding, must be delivered between weeks 34 and 36 6/7. Surgical treatment must include sequential interventions that may vary depending on the characteristics of the lesion, the clinical condition of the patient and the availability of resources. The surgical options (total and subtotal hysterectomy, one-stage conservative surgical management and watchful waiting) must be included in a protocol known by the entire interdisciplinary team. In situations in which an antepartum diagnosis is lacking, that is to say, in the face of intraoperative finding of PAS (evidence of purple bulging or neovascularization of the anterior aspect of the uterus), and the participation of untrained personnel, three options are considered: Option 1: In the absence of indication of immediate delivery or of vaginal delivery, the recommendation is to postpone the cesarean section (close the laparotomy before incising the uterus) until the recommended resources for safe surgery are secured. Option 2: If there is an indication for immediate delivery (e.g., non-reassuring fetal status) but there is absence of vaginal bleeding or indication for immediate PAS management, a two-stage management is suggested: cesarean section avoiding placental incision, followed by uterine repair and abdominal closure, until the availability of the recommended resources for safe surgery is ascertained. Option 3: In the event of vaginal bleeding that prevents definitive PAS management, the fetus must be delivered through the uterine fundus, followed by uterine repair and reassessment of the situation. Sometimes, fetal delivery diminishes placental flow and vaginal bleeding is reduced or disappears, enabling the possibility to postpone definitive management of PAS. In case of persistent significant bleeding, hysterectomy should be performed, using all available resources: manual aortic compression, immediate call to the surgeons with the best available training, telemedicine support from expert teams in other hospitals. If a patient with risk factors for PAS (e.g., myomectomy or previous cesarean section) has a retained placenta after vaginal delivery, it is advisable to confirm the possibility of such diagnosis (by means of ultrasound, for example) before proceeding to manual extraction of the placenta. Conclusions: It is our hope that this first Colombian consensus on PAS will serve as a basis for additional discussions and collaborations that can result in improved clinical outcomes for women affected by this condition. Additional research will be required in order to evaluate the applicability and effectiveness of these recommendations.

Introducción: el espectro de acretismo placentario (EAP) es una condición asociada a sangrado masivo posparto y mortalidad materna. Las guías de manejo publicadas en países de altos ingresos recomiendan la participación de grupos interdisciplinarios en hospitales con recursos suficientes para realizar procedimientos complejos. Sin embargo, algunas de las recomendaciones de estas guías resultan difíciles de aplicar en países de bajos y medianos ingresos. Objetivos: este consenso busca formular recomendaciones generales para el tratamiento del EAP en Colombia. Materiales y métodos: en el consenso participaron 23 panelistas, quienes respondieron 31 preguntas sobre el tratamiento de EAP. Los panelistas fueron seleccionados con base en la participación en dos encuestas realizadas para determinar la capacidad resolutiva de hospitales en el país y la región. Se utilizó la metodología Delphi modificada, incorporando dos rondas sucesivas de discusión. Para emitir las recomendaciones el grupo tomó en cuenta la opinión de los participantes, que lograron un consenso mayor al 80 %, así como las barreras y los facilitadores para su implementación. Resultados: el consenso formuló cinco recomendaciones integrando las respuestas de los panelistas. Recomendación 1. Las instituciones de atención primaria deben realizar búsqueda activa de EAP en pacientes con factores de riesgo: placenta previa e historia de miomectomía o cesárea en embarazo previo. En caso de haber signos sugestivos de EAP por ecografía, las pacientes deben ser remitidas de manera inmediata, sin tener una edad gestacional mínima, a hospitales reconocidos como centros de referencia. Las modalidades virtuales de comunicación y atención en salud pueden facilitar la interacción entre las instituciones de atención primaria y los centros de referencia para EAP. Se debe evaluar el beneficio y riesgo de las modalidades de telemedicina. Recomendación 2. Es necesario que se definan hospitales de referencia para EAP en cada región de Colombia, asegurando el cubrimiento de la totalidad del territorio nacional. Es aconsejable concentrar el flujo de pacientes afectadas por esta condición en unos pocos hospitales, donde haya equipos de cirujanos con entrenamiento específico en EAP, disponibilidad de recursos especializados y un esfuerzo institucional por mejorar la calidad de atención, en busca de tener mejores resultados en la salud de las gestantes con esta condición. Para lograr ese objetivo los participantes recomiendan que los entes reguladores de la prestación de servicios de salud a nivel nacional, regional o local vigilen el proceso de remisión de estas pacientes, facilitando rutas administrativas en caso de que no exista contrato previo entre el asegurador y el hospital o la clínica seleccionada (IPS). Recomendación 3. En los centros de referencia para pacientes con EAP se invita a la creación de equipos que incorporen un grupo fijo de especialistas (obstetras, urólogos, cirujanos generales, radiólogos intervencionistas) encargados de atender todos los casos de EAP. Es recomendable que esos grupos interdisciplinarios utilicen el modelo de "paquete de intervención" como guía para la preparación de los centros de referencia para EAP. Este modelo consta de las siguientes actividades: preparación de los servicios, prevención e identificación de la enfermedad, respuesta ante la presentación de la enfermedad, aprendizaje luego de cada evento. La telemedicina facilita el tratamiento de EAP y debe ser tenida en cuenta por los grupos interdisciplinarios que atienden esta enfermedad. Recomendación 4. Los residentes de Obstetricia deben recibir instrucción en maniobras útiles para la prevención y el tratamiento del sangrado intraoperatorio masivo por placenta previa y EAP, tales como: la compresión manual de la aorta, el torniquete uterino, el empaquetamiento pélvico, el bypass retrovesical y la maniobra de Ward. Los conceptos básicos de diagnóstico y tratamiento de EAP deben incluirse en los programas de especialización en Ginecología y Obstetricia en Colombia. En los centros de referencia del EAP se deben ofrecer programas de entrenamiento a los profesionales interesados en mejorar sus competencias en EAP de manera presencial y virtual. Además, deben ofrecer soporte asistencial remoto (telemedicina) permanente a los demás hospitales en su región, en relación con pacientes con esa enfermedad. Recomendación 5. La finalización de la gestación en pacientes con sospecha de EAP y placenta previa, por imágenes diagnósticas, sin evidencia de sangrado vaginal activo, debe llevarse a cabo entre las semanas 34 y 36 6/7. El tratamiento quirúrgico debe incluir intervenciones secuenciales que pueden variar según las características de la lesión, la situación clínica de la paciente y los recursos disponibles. Las opciones quirúrgicas (histerectomía total y subtotal, manejo quirúrgico conservador en un paso y manejo expectante) deben incluirse en un protocolo conocido por todo el equipo interdisciplinario. En escenarios sin diagnóstico anteparto, es decir, ante un hallazgo intraoperatorio de EAP (evidencia de abultamiento violáceo o neovascularización de la cara anterior del útero), y con participación de personal no entrenado, se plantean tres situaciones: Primera opción: en ausencia de indicación de nacimiento inmediato o sangrado vaginal, se recomienda diferir la cesárea (cerrar la laparotomía antes de incidir el útero) hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura. Segunda opción: ante indicación de nacimiento inmediato (por ejemplo, estado fetal no tranquilizador), pero sin sangrado vaginal o indicación de manejo inmediato de EAP, se sugiere realizar manejo en dos tiempos: se realiza la cesárea evitando incidir la placenta, seguida de histerorrafia y cierre de abdomen, hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura. Tercera opción: en presencia de sangrado vaginal que hace imposible diferir el manejo definitivo de EAP, es necesario extraer el feto por el fondo del útero, realizar la histerorrafia y reevaluar. En ocasiones, el nacimiento del feto disminuye el flujo placentario y el sangrado vaginal se reduce o desaparece, lo que hace posible diferir el manejo definitivo de EAP. Si el sangrado significativo persiste, es necesario continuar con la histerectomía haciendo uso de los recursos disponibles: compresión manual de la aorta, llamado inmediato a los cirujanos con mejor entrenamiento disponible, soporte de grupos expertos de otros hospitales a través de telemedicina. Si una paciente con factores de riesgo para EAP (por ejemplo, miomectomía o cesárea previa) presenta retención de placenta posterior al parto vaginal, es recomendable confirmar la posibilidad de dicho diagnóstico (por ejemplo, realizando una ecografía) antes de intentar la extracción manual de la placenta. Conclusiones: esperamos que este primer consenso colombiano de EAP sirva como base para discusiones adicionales y trabajos colaborativos que mejoren los resultados clínicos de las mujeres afectadas por esta enfermedad. Evaluar la aplicabilidad y efectividad de las recomendaciones emitidas requerirá investigaciones adicionales.

Consenso Colombiano de Tratamiento del Espectro de Acretismo Placentario (EAP) / Colombian Consensus on the Treatment of Placenta Accreta Spectrum (PAS)

RESUMEN Introducción: el espectro de acretismo placentario (EAP) es una condición asociada a sangrado masivo posparto y mortalidad materna. Las guías de manejo publicadas en países de altos ingresos recomiendan la participación de grupos interdisciplinarios en hospitales con recursos suficientes para realizar procedimientos complejos. Sin embargo, algunas de las recomendaciones de estas guías resultan difíciles de aplicar en países de bajos y medianos ingresos. Objetivos: este consenso busca formular recomendaciones generales para el tratamiento del EAP en Colombia. Materiales y métodos: en el consenso participaron 23 panelistas, quienes respondieron 31 preguntas sobre el tratamiento de EAP. Los panelistas fueron seleccionados con base en la participación en dos encuestas realizadas para determinar la capacidad resolutiva de hospitales en el país y la región. Se utilizó la metodología Delphi modificada, incorporando dos rondas sucesivas de discusión. Para emitir las recomendaciones el grupo tomó en cuenta la opinión de los participantes, que lograron un consenso mayor al 80 %, así como las barreras y los facilitadores para su implementación. Resultados: el consenso formuló cinco recomendaciones integrando las respuestas de los panelistas. Recomendación 1. Las instituciones de atención primaria deben realizar búsqueda activa de EAP en pacientes con factores de riesgo: placenta previa e historia de miomectomía o cesárea en embarazo previo. En caso de haber signos sugestivos de EAP por ecografía, las pacientes deben ser remitidas de manera inmediata, sin tener una edad gestacional mínima, a hospitales reconocidos como centros de referencia. Las modalidades virtuales de comunicación y atención en salud pueden facilitar la interacción entre las instituciones de atención primaria y los centros de referencia para EAP. Se debe evaluar el beneficio y riesgo de las modalidades de telemedicina. Recomendación 2. Es necesario que se definan hospitales de referencia para EAP en cada región de Colombia, asegurando el cubrimiento de la totalidad del territorio nacional. Es aconsejable concentrar el flujo de pacientes afectadas por esta condición en unos pocos hospitales, donde haya equipos de cirujanos con entrenamiento específico en EAP, disponibilidad de recursos especializados y un esfuerzo institucional por mejorar la calidad de atención, en busca de tener mejores resultados en la salud de las gestantes con esta condición. Para lograr ese objetivo los participantes recomiendan que los entes reguladores de la prestación de servicios de salud a nivel nacional, regional o local vigilen el proceso de remisión de estas pacientes, facilitando rutas administrativas en caso de que no exista contrato previo entre el asegurador y el hospital o la clínica seleccionada (IPS). Recomendación 3. En los centros de referencia para pacientes con EAP se invita a la creación de equipos que incorporen un grupo fijo de especialistas (obstetras, urólogos, cirujanos generales, radiólogos intervencionistas) encargados de atender todos los casos de EAP. Es recomendable que esos grupos interdisciplinarios utilicen el modelo de "paquete de intervención" como guía para la preparación de los centros de referencia para EAP. Este modelo consta de las siguientes actividades: preparación de los servicios, prevención e identificación de la enfermedad, respuesta ante la presentación de la enfermedad, aprendizaje luego de cada evento. La telemedicina facilita el tratamiento de EAP y debe ser tenida en cuenta por los grupos interdisciplinarios que atienden esta enfermedad. Recomendación 4. Los residentes de Obstetricia deben recibir instrucción en maniobras útiles para la prevención y el tratamiento del sangrado intraoperatorio masivo por placenta previa y EAP, tales como: la compresión manual de la aorta, el torniquete uterino, el empaquetamiento pélvico, el bypass retrovesical y la maniobra de Ward. Los conceptos básicos de diagnóstico y tratamiento de EAP deben incluirse en los programas de especialización en Ginecología y Obstetricia en Colombia. En los centros de referencia del EAP se deben ofrecer programas de entrenamiento a los profesionales interesados en mejorar sus competencias en EAP de manera presencial y virtual. Además, deben ofrecer soporte asistencial remoto (telemedicina) permanente a los demás hospitales en su región, en relación con pacientes con esa enfermedad. Recomendación 5. La finalización de la gestación en pacientes con sospecha de EAP y placenta previa, por imágenes diagnósticas, sin evidencia de sangrado vaginal activo, debe llevarse a cabo entre las semanas 34 y 36 6/7. El tratamiento quirúrgico debe incluir intervenciones secuenciales que pueden variar según las características de la lesión, la situación clínica de la paciente y los recursos disponibles. Las opciones quirúrgicas (histerectomía total y subtotal, manejo quirúrgico conservador en un paso y manejo expectante) deben incluirse en un protocolo conocido por todo el equipo interdisciplinario. En escenarios sin diagnóstico anteparto, es decir, ante un hallazgo intraoperatorio de EAP (evidencia de abultamiento violáceo o neovascularización de la cara anterior del útero), y con participación de personal no entrenado, se plantean tres situaciones: Primera opción: en ausencia de indicación de nacimiento inmediato o sangrado vaginal, se recomienda diferir la cesárea (cerrar la laparotomía antes de incidir el útero) hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura. Segunda opción: ante indicación de nacimiento inmediato (por ejemplo, estado fetal no tranquilizador), pero sin sangrado vaginal o indicación de manejo inmediato de EAP, se sugiere realizar manejo en dos tiempos: se realiza la cesárea evitando incidir la placenta, seguida de histerorrafia y cierre de abdomen, hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura. Tercera opción: en presencia de sangrado vaginal que hace imposible diferir el manejo definitivo de EAP, es necesario extraer el feto por el fondo del útero, realizar la histerorrafia y reevaluar. En ocasiones, el nacimiento del feto disminuye el flujo placentario y el sangrado vaginal se reduce o desaparece, lo que hace posible diferir el manejo definitivo de EAP. Si el sangrado significativo persiste, es necesario continuar con la histerectomía haciendo uso de los recursos disponibles: compresión manual de la aorta, llamado inmediato a los cirujanos con mejor entrenamiento disponible, soporte de grupos expertos de otros hospitales a través de telemedicina. Si una paciente con factores de riesgo para EAP (por ejemplo, miomectomía o cesárea previa) presenta retención de placenta posterior al parto vaginal, es recomendable confirmar la posibilidad de dicho diagnóstico (por ejemplo, realizando una ecografía) antes de intentar la extracción manual de la placenta. Conclusiones: esperamos que este primer consenso colombiano de EAP sirva como base para discusiones adicionales y trabajos colaborativos que mejoren los resultados clínicos de las mujeres afectadas por esta enfermedad. Evaluar la aplicabilidad y efectividad de las recomendaciones emitidas requerirá investigaciones adicionales.

ABSTRACT Introduction: Placenta accreta spectrum (PAS) is a condition associated with massive postpartum bleeding and maternal mortality. Management guidelines published in high income countries recommend the participation of interdisciplinary teams in hospitals with sufficient resources for performing complex procedures. However, some of the recommendations contained in those guidelines are difficult to implement in low and medium income countries. Objectives: The aim of this consensus is to draft general recommendations for the treatment of PAS in Colombia Materials and Methods: Twenty-three panelists took part in the consensus with their answers to 31 questions related to the treatment of PAS. The panelists were selected based on participation in two surveys designed to determine the resolution capabilities of national and regional hospitals. The modified Delphi methodology was used, introducing two successive discussion rounds. The opinions of the participants, with a consensus of more than 80 %, as well as implementation barriers and facilitators, were taken into consideration in order to issue the recommendations. Results: The consensus drafted five recommendations, integrating the answers of the panelists. Recommendation 1. Primary care institutions must undertake active search of PAS in patients with risk factors: placenta praevia and history of myomectomy or previous cesarean section. In case of ultrasound signs suggesting PAS, patients must be immediately referred, without a minimum gestational age, to hospitals recognized as referral centers. Online communication and care modalities may facilitate the interaction between primary care institutions and referral centers for PAS. The risks and benefits of telemedicine modalities must be weighed. Recommendation 2. Referral hospitals for PAS need to be defined in each region of Colombia, ensuring coverage throughout the national territory. It is advisable to concentrate the flow of patients affected by this condition in a few hospitals with surgical teams specifically trained in PAS, availability of specialized resources, and institutional efforts at improving quality of care with the aim of achieving better health outcomes in pregnant women with this condition. To achieve this goal, participants recommend that healthcare regulatory agencies at a national and regional level should oversee the process of referral for these patients, expediting administrative pathways in those cases in which there is no prior agreement between the insurer and the selected hospital or clinic. Recommendation 3. Referral centers for patients with PAS are urged to build teams consisting of a fixed group of specialists (obstetricians, urologists, general surgeons, interventional radiologists) entrusted with the care of all PAS cases. It is advisable for these interdisciplinary teams to use the "intervention bundle" model as a guidance for building PAS referral centers. This model comprises the following activities: service preparedness, disease prevention and identification, response to the occurrence of the disease, and debriefing after every event. Telemedicine facilitates PAS treatment and should be taken into consideration by interdisciplinary teams caring for this disease. Recommendation 4. Obstetrics residents must be instructed in the performance of maneuvers that are useful for the prevention and treatment of massive intraoperative bleeding due to placenta praevia and PAS, including manual aortic compression, uterine tourniquet, pelvic packing, retrovesical bypass, and Ward maneuver. Specialization Obstetrics and Gynecology programs in Colombia must include the basic concepts of the diagnosis and treatment of PAS. Referral centers for PAS must offer online and in-person training programs for professionals interested in improving their competencies in PAS. Moreover, they must offer permanent remote support (telemedicine) to other hospitals in their region for patients with this condition. Recommendation 5. Patients suspected of having PAS and placenta praevia based on imaging, with no evidence of active vaginal bleeding, must be delivered between weeks 34 and 36 6/7. Surgical treatment must include sequential interventions that may vary depending on the characteristics of the lesion, the clinical condition of the patient and the availability of resources. The surgical options (total and subtotal hysterectomy, one-stage conservative surgical management and watchful waiting) must be included in a protocol known by the entire interdisciplinary team. In situations in which an antepartum diagnosis is lacking, that is to say, in the face of intraoperative finding of PAS (evidence of purple bulging or neovascularization of the anterior aspect of the uterus), and the participation of untrained personnel, three options are considered: Option 1: In the absence of indication of immediate delivery or of vaginal delivery, the recommendation is to postpone the cesarean section (close the laparotomy before incising the uterus) until the recommended resources for safe surgery are secured. Option 2: If there is an indication for immediate delivery (e.g., non-reassuring fetal status) but there is absence of vaginal bleeding or indication for immediate PAS management, a two-stage management is suggested: cesarean section avoiding placental incision, followed by uterine repair and abdominal closure, until the availability of the recommended resources for safe surgery is ascertained. Option 3: In the event of vaginal bleeding that prevents definitive PAS management, the fetus must be delivered through the uterine fundus, followed by uterine repair and reassessment of the situation. Sometimes, fetal delivery diminishes placental flow and vaginal bleeding is reduced or disappears, enabling the possibility to postpone definitive management of PAS. In case of persistent significant bleeding, hysterectomy should be performed, using all available resources: manual aortic compression, immediate call to the surgeons with the best available training, telemedicine support from expert teams in other hospitals. If a patient with risk factors for PAS (e.g., myomectomy or previous cesarean section) has a retained placenta after vaginal delivery, it is advisable to confirm the possibility of such diagnosis (by means of ultrasound, for example) before proceeding to manual extraction of the placenta. Conclusions: It is our hope that this first Colombian consensus on PAS will serve as a basis for additional discussions and collaborations that can result in improved clinical outcomes for women affected by this condition. Additional research will be required in order to evaluate the applicability and effectiveness of these recommendations.

Diversidad de escarabajos coprófagos (Coleoptera: Scarabaeidae) en tres zonas urbanizadas del Caribe colombiano / Diversity of dung beetles (Coleoptera: Scarabaeidae) in three urban areas from Colombian Caribbean

Resumen En el presente trabajo se estudia la diversidad de escarabajos coprófagos en tres zonas urbanizadas del departamento de Sucre, Colombia, cada una con características ecológicas distintas. Los individuos fueron capturados con trampas de caída cebadas. Se analizaron el esfuerzo de muestreo, las curvas de rango-abundancia y los índices de diversidad alfa y beta. Se capturaron 710 individuos, agrupados en nueve géneros y 13 especies. El análisis de completitud arrojó valores por encima del 97%. El ensamble más diverso en cualquiera de los tres órdenes de "q" se encontró en la zona que alberga edificaciones, jardines y un parche de bosque de vegetación secundaria, seguido por una zona de pastizales, con pocas edificaciones; el ensamble de menor diversidad correspondió a la zona rodeada de edificaciones y con escasa cobertura vegetal. El índice de Sorensen-Dice arrojó una similitud total entre las tres zonas del 38%. Las curvas de rango-abundancia mostraron mayor equidad de especies en la zona más diversa. Los resultados indicaron que la composición del ensamble de escarabajos depende de las condiciones ambientales y el grado de urbanización. Así mismo, se evidenció que algunas especies pueden tener alta adaptabilidad y que algunas de ellas corren el riesgo potencial de presentar eventos de extinción local.

Abstract In this paper, diversity and composition of dung beetles assemblage was study in three urbanized areas with different ecological characteristics from Sucre department , Colombia. Individuals were captured with baited pitfall traps. Sampling effort, range-abundance curves, alpha and beta diversity indices were estimated and compared among the sites. Seven hundred ten individuals grouped into nine genera and 13 species were recorded. The completeness analysis yielded values above 97%. The most diverse assemblage in any of the three orders of "q" was found in the site with a mixture of buildings, gardens, and a patch of secondary vegetation forest, followed by the site with few facilities and open green spaces, and the least diverse site corresponded to the area surrounded by buildings with little vegetation cover. Sorensen-Dice index similarity among the three sites was 38%. The range-abundance curves showed higher species equitability in the most diverse site. The results show that the beetle assemblage composition depends on environmental conditions and the degree of urbanization. It was also evident that some species have high adaptability to urban spaces and others are potentially at risk of local extinction events.

How Temperatures May Affect the Synthesis of Fatty Acids during Olive Fruit Ripening: Genes at Work in the Field.

A major concern for olive cultivation in many extra-Mediterranean regions is the adaptation of recently introduced cultivars to environmental conditions different from those prevailing in the original area, such as the Mediterranean basin. Some of these cultivars can easily adapt their physiological and biochemical parameters in new agro-environments, whereas others show unbalanced values of oleic acid content. The objective of this study was to evaluate the effects of the thermal regime during oil synthesis on the expression of fatty acid desaturase genes and on the unsaturated fatty acid contents at the field level. Two cultivars (Arbequina and Coratina) were included in the analysis over a wide latitudinal gradient in Argentina. The results suggest that the thermal regime exerts a regulatory effect at the transcriptional level on both OeSAD2 and OeFAD2-2 genes and that this regulation is cultivar-dependent. It was also observed that the accumulated thermal time affects gene expression and the contents of oleic and linoleic acids in cv. Arbequina more than in Coratina. The fatty acid composition of cv. Arbequina is more influenced by the temperature regime than Coratina, suggesting its greater plasticity. Overall, findings from this study may drive future strategies for olive spreading towards areas with different or extreme thermal regimes serve as guidance for the evaluation olive varietal patrimony.

Successful vaginal delivery and maternal and perinatal outcomes in patients with a history of cesarean section and labor trial: cross-sectional study / Parto vaginal exitoso y resultados maternos y perinatales en pacientes con antecedente de cesárea y prueba de trabajo de parto: estudio de corte transversal

Objectives: To determine the proportion of successful vaginal deliveries in women with prior cesarean section; to describe maternal and perinatal complications; and to examine the factors associated with vaginal delivery. Materials and methods: Descriptive cross-sectional study of women with a history of cesarean delivery, gestational age of more than 24 weeks, singleton live fetuses, with prior vaginal delivery who received care in a high complexity public institution in 2019. Patients with a history of more than one cesarean section or myomectomy were excluded. Consecutive sampling was used. Sociodemographic and obstetric variables, delivery route and maternal and perinatal complications were measured. A descriptive analysis as well as a multivariate exploratory analysis of the factors associated with successful vaginal delivery were carried out. Results: Among 286 pregnant women included, the percentage of successful vaginal deliveries was 74.5 %. Maternal complications were identified in 3.2 % of vaginal delivery cases and in 6.8 % of cesarean births. Complications occurred in 1.3 % of all live neonates; there were 2 perinatal deaths. An association was found between successful vaginal delivery and a history of prior vaginal delivery (OR: 2.7; 95 % CI: 1.15-6.29); a Bishop score greater than 6 (OR: 2.2; 95 % CI: 1.03-4.56); spontaneous labor initiation (OR: 4.5; IC 95 % CI: 2.07-9.6); and maternal age under 30 years (OR:2.28; 95 % CI: 1.2-4.2). Conclusions: Vaginal delivery is a safe option to consider in patients with prior cesarean section, in particular in cases of spontaneous labor initiation or prior vaginal delivery. Prospective cohorts are needed in order to confirm these findings.

Objetivos: determinar la proporción de parto vaginal exitoso en mujeres con cesárea previa, describir las complicaciones maternas y perinatales, y realizar una aproximación a los factores asociados al parto vaginal. Materiales y métodos: estudio de corte transversal descriptivo. Se incluyeron mujeres con antecedente de un parto por cesárea, con edad gestacional mayor a 24 semanas y fetos únicos vivos que tuvieron prueba de parto vaginal, atendidas en una institución pública de alta complejidad en 2019. Se excluyeron aquellas pacientes con antecedente de más de una cesárea o miomectomía. Muestreo consecutivo. Se midieron variables sociodemográficas, obstétricas, vía del parto y complicaciones maternas y perinatales. Se hace análisis descriptivo y un análisis exploratorio multivariado de los factores asociados al parto vaginal exitoso. Resultados: de 286 gestantes incluidas, el porcentaje de éxito de parto vaginal fue del 74,5 %. Se identificaron complicaciones maternas en el 3,2 % de los partos vaginales y en el 6,8 % de las cesáreas. El 1,3 % de los recién nacidos tuvo alguna complicación. Hubo 2 muertes perinatales. Se encontró asociación entre parto vaginal exitoso y tener antecedente de parto vaginal (OR: 2,7; IC 95 %: 1,15-6,29); puntaje de Bishop mayor de 6 (OR: 2,2; IC 95 %: 1,03-4,56); inicio de trabajo de parto espontáneo (OR: 4,5; IC 95 %: 2,07-9,6); y edad materna menor de 30 años (OR: 2,28; IC 95 %: 1,2-4,2). Conclusiones: el parto vaginal es una opción segura para considerar en pacientes con cesárea anterior, especialmente si inician trabajo de parto espontáneo o han tenido un parto vaginal previamente. Se requieren cohortes prospectivas para confirmar estos hallazgos.

Ouabain Enhances Gap Junctional Intercellular Communication by Inducing Paracrine Secretion of Prostaglandin E2.

Ouabain is a cardiac glycoside that has been described as a hormone, with interesting effects on epithelial physiology. We have shown previously that ouabain induces gap junctional intercellular communication (GJIC) in wild, sensitive cells (MDCK-S), but not in cells that have become insensitive (MDCK-I) by modifying their Na+-K+-ATPase. We have also demonstrated that prostaglandin E2 (PGE2) is able to induce increased GJIC by a mechanism other than ouabain, that does not depend on Na+-K+-ATPase. In this work we show, by dye transfer assays, that when MDCK-S and MDCK-I are randomly mixed, to form monolayers, the latter stablish GJIC, because of stimulation by a compound released to the extracellular media, by MDCK-S cells, after treatment with ouabain, as evidenced by the fact that monolayers of only MDCK-I cells, treated with a conditioned medium (CM) that is obtained after incubation of MDCK-S monolayers with ouabain, significantly increase their GJIC. The further finding that either (1) pre-treatment with COX-2 inhibitors or (2) addition to CM of antagonists of EP2 receptor abolish CM's ability to induce GJIC in MDCK-I monolayers indicate that PGE2 is the GJIC-inducing compound. Therefore, these results indicate that, in addition to direct stimulation, mediated by Na+-K+-ATPase, ouabain enhances GJIC indirectly through the paracrine production of PGE2.

Prostaglandin E2 Enhances Gap Junctional Intercellular Communication in Clonal Epithelial Cells.

Prostaglandins are a group of lipids that produce diverse physiological and pathological effects. Among them, prostaglandin E2 (PGE2) stands out for the wide variety of functions in which it participates. To date, there is little information about the influence of PGE2 on gap junctional intercellular communication (GJIC) in any type of tissue, including epithelia. In this work, we set out to determine whether PGE2 influences GJIC in epithelial cells (MDCK cells). To this end, we performed dye (Lucifer yellow) transfer assays to compare GJIC of MDCK cells treated with PGE2 and untreated cells. Our results indicated that (1) PGE2 induces a statistically significant increase in GJIC from 100 nM and from 15 min after its addition to the medium, (2) such effect does not require the synthesis of new mRNA or proteins subunits but rather trafficking of subunits already synthesized, and (3) such effect is mediated by the E2 receptor, which, in turn, triggers a signaling pathway that includes activation of adenylyl cyclase and protein kinase A (PKA). These results widen the knowledge regarding modulation of gap junctional intercellular communication by prostaglandins.

Grain polydispersity and coherent crystal reorientations are features to foster stress hotspots in polycrystalline alloys under load.

The mechanical properties of metallic alloys are controlled through the design of their polycrystalline structure via heat treatments. For single-phase microstructures, they aim to achieve a particular average grain diameter to leverage stress hardening or softening. The stochastic nature of the recrystallization process generates a grain size distribution, and the randomness of the crystallographic orientation determines the anisotropy of a mechanical response. We developed a multiscale computational formalism to capture the collective mechanical response of polycrystalline microstructures at unprecedented length scales. We found that for an averaged grain size, the mechanical response is highly dependent on the grain size distribution. The simulations reveal the topological conditions that promote coherent grain texturization and grain growth inhibition during stress relaxation. We identify the microstructural features that are responsible for the appearance of stress hotspots. Our results provide the elusive evidence of how stress hotspots are ideal precursors for plastic and creep failure.

A new species and distribution records of Dichotomius Hope, 1838 (Coleoptera: Scarabaeidae: Scarabaeinae) in Colombia.

Dichotomius (Dichotomius) quadrilobatus new species (Coleoptera: Scarabaeidae: Scarabaeinae: Dichotomiini), from western Amazonia (Brazil, Colombia, Ecuador and Peru) is described and its putative systematic position within the Dichotomius boreus species group is discussed. An updated identification key to the species of the Dichotomius boreus species group is provided. Additionally, Dichotomius (Selenocopris) fortepunctatus Luederwaldt, 1923 is recorded for the first time in Colombia.

Review of Scatimus Erichson (Coleoptera: Scarabaeidae) in Colombia with the description of a new species.

We present a review of Scatimus Erichson (Coleoptera: Scarabaeidae: Scarabaeinae: Ateuchini: Scatimina) in Colombia, with the description of S. strenua new species from the Central Andes (Antioquia Department). Records of S. strandi Balthasar from southwestern Colombia (Caquetá and Nariño Departments) are validated. The distributions of S. ovatus Harold from the Magdalena, Chocó-Darién, and Sierra Nevada de Santa Marta provinces and S. fernandezi Martínez in the eastern foothills of the Eastern Cordillera (Orinoco-Amazon) are confirmed. New departmental records and distribution maps for Colombia are presented; an updated key for the taxonomic identification of Scatimus is included. With a total of four species, Colombia has the second highest Scatimus species richness of any country.

Manejo de la terapia anticoagulante durante el embarazo / Management of anticoagulant therapy during pregnancy

Resumen El embarazo se asocia con 5 a 10 veces mayor riesgo de enfermedad tromboembólica venosa, convirtiéndose en un escenario particular y complejo para la anticoagulación dada la necesidad de seguridad fetal y limitada representación en estudios de eficacia disponibles. Durante la gestación existen tres principales situaciones clínicas: la enfermedad tromboembólica venosa sin factor de riesgo precipitante, el síndrome antifosfolípido y las portadoras de válvulas mecánicas protésicas; todas con un alto riesgo de complicaciones materno-fetales, por lo que es vital conocer los anticoagulantes disponibles para cada patología, su evidencia científica, eventos adversos y características farmacológicas con el fin de realizar el mejor abordaje terapéutico y disminuir complicaciones asociadas. El objetivo es describir los avances de los anticoagulantes en escenarios clínicos de mayor impacto antes de la concepción, durante el embarazo y postparto y servir de herramienta con el fin de realizar el mejor abordaje terapéutico y disminuir complicaciones asociadas. MÉD.UIS.2020;33(2):65-73.

Abstract Pregnancy is associated with a 5 to 10-fold increased risk of venous thromboembolic disease, making it a complex setting for anticoagulation, given the need for fetal safety and limited representation in available efficacy studies. During pregnancy there are three main clinical situations: venous thromboembolic disease without a precipitating risk factor, antiphospholipid syndrome and prosthetic mechanical valve carriers; all with a high risk of maternal-fetal complications, so it is vital to know the anticoagulants available for each pathology, their scientific evidence, adverse events and pharmacological characteristics in order to perform the best therapeutic approach and reduce associated complications. The objective is to describe the advances of anticoagulants in clinical scenarios of greater impact before conception, during pregnancy and postpartum and to serve as a tool in order to carry out the best therapeutic approach and reduce associated complications. MÉD.UIS.2020;33(2):65-73.

[SAFETY OF THE TREATMENT FOR VOLUNTARY PREGNANCY TERMINATION BY GESTATIONAL AGE. MEDELLÍN, COLOMBIA, 2013-2014].

OBJECTIVE: To describe the safety of medical and surgical treatments used in women seeking voluntary pregnancy termination. METHODS: Historical cohort of all pregnant women with up to 26 weeks of gestation who received treatment for voluntary pregnancy termination in a referral institution in Medellín, Colombia, between January 2013 and December 2014.Sampling was consecutive. Measured variables included sociodemographic and obstetric variables, undesired effects, and complications of the voluntary pregnancy termination treatment. A descriptive analysis was carried out. RESULTS: Overall, 87 women were included. The mean age at the time of termination was 24 years (inter-quartile range [IQR] = 12), 69.0% were single, and 73,4% were unemployed. The main reason for termination was the risk to the mother's health in 61,0% of cases, followed by a history of sexual violence in 26.4% and fetal malformations in 12.6%; a total of 70 women (80,4%) had less than 18 weeks of gestation and were treated with misoprostol plus manual vacuum aspiration; 17 (19,6%) had between 18 and 26 weeks of gestation and were treated with misoprostol followed by dilation and curettage. The first group (gestational age <18 weeks) experienced undesired effects such as pain and vomiting; in the second group (> or equal to 18 weeks), 41.0% of the women experienced hemorrhage. CONCLUSIONS: The risk to the mother's health was the main reason for the termination of pregnancy. Termination before 18 weeks was found to be safe, while termination between 18 and 26 weeks using misoprostol and curettage was associated with a high frequency of hemorrhage.

TITULO: SEGURIDAD DEL TRATAMIENTO DE LA INTERRUPCIÓN VOLUNTARIA DEL EMBARAZO SEGÚN EDAD GESTACIONAL EN MEDELLÍN, COLOMBIA, 2013-2014. OBJETIVO: describir la seguridad del tratamiento médico-quirúrgico empleado en mujeres que acuden a interrupción voluntaria del embarazo. METODOS: cohorte histórica. Se incluyeron todas las mujeres embarazadas, hasta con 26 semanas de edad gestacional, a quienes se les dio tratamiento para interrupción voluntaria del embarazo en una institución de referencia en Medellín, Colombia, entre enero de 2013 y diciembre de 2014. Muestreo consecutivo. Se midieron las variables sociodemográficas obstétricas, los efectos no deseados y las complicaciones en el tratamiento de la interrupción voluntaria del embarazo. Se hizo análisis descriptivo. RESULTADOS: se incluyeron 87 mujeres, la mediana de edad de las mujeres al momento de la interrupción fue de 24 años (rango intercuartílico [Rq] = 12), el 69,0 % estaban solteras y el 73,4% desempleadas. La principal causa de interrupción fue el riesgo para la salud de la madre en el 61,0 %, seguido por antecedente de violencia sexual en el 26,4 % y malformaciones fetales en el 12,6 %; un total de 70 mujeres (80,4 %) tenía menos de 18 semanas de gestación y fueron tratadas con misoprostol más aspiración manual endouterina; 17 (19,6%) tenían entre 18 y 26 semanas de gestación, las cuales recibieron misoprostol y legrado. El primer grupo (edad gestacional <18 semanas) no presentó complicaciones, solo efectos no deseados tales como dolor y vómito; el segundo grupo (> o igual a 18 semanas) presentó hemorragia en el 41 % de los casos. CONCLUSIONES: el riesgo para la salud materna constituyó el principal motivo para la interrupción del embarazo. La interrupción del embarazo antes de la semana 18 es segura, entre las semanas 18 a 26, con misoprostol y legrado uterino, se acompañó de una alta frecuencia de hemorragia.

Taxonomic reassessment of the genus Dichotomius (Coleoptera: Scarabaeinae) through integrative taxonomy.

Dung beetles of the subfamily Scarabaeinae are widely recognised as important providers of multiple ecosystem services and are currently experiencing revisions that have improved our understanding of higher-level relationships in the subfamily. However, the study of phylogenetic relationships at the level of genus or species is still lagging behind. In this study we investigated the New World beetle genus Dichotomius, one of the richest within the New World Scarabaeinae, using the most comprehensive molecular and morphological dataset for the genus to date (in terms of number of species and individuals). Besides evaluating phylogenetic relationships, we also assessed species delimitation through a novel Bayesian approach (iBPP) that enables morphological and molecular data to be combined. Our findings support the monophyly of the genus Dichotomius but not that of the subgenera Selenocopris and Dichotomius sensu stricto (s.s). Also, our results do not support the recent synonymy of Selenocopris with Luederwaldtinia. Some species-groups within the genus were recovered, and seem associated with elevational distribution. Our species delimitation analyses were largely congruent irrespective of the set of parameters applied, but the most robust results were obtained when molecular and morphological data were combined. Although our current sampling and analyses were not powerful enough to make definite interpretations on the validity of all species evaluated, we can confidently recognise D. nisus, D. belus and D. mamillatus as valid and well differentiated species. Overall, our study provides new insights into the phylogenetic relationships and classification of dung beetles and has broad implications for their systematics and evolutionary analyses.

Injection of mRNA isolated from trophozoites of Giardia intestinalis induces expression of three types of chloride currents in Xenopus laevis oocytes.

Giardia lamblia is one of the most important worldwide causes of intestinal infections, yet little is known about its cellular physiology, especially the diversity of ionic channels that this parasite expresses. In this work, we show that injection of mRNA isolated from trophozoites of Giardia, into Xenopus laevis oocytes, induces expression of three types of chloride currents (here referred to as ICl-G1, ICl-G2, and ICl-G3), which have different biophysical and pharmacological properties. ICl-G1 currents show inward rectification and voltage dependence are enhanced by hypotonicity, show a selectivity sequence of (I > Br > Cl > F), and are inhibited by NPPB, DIDS, SITS, 9AC, DPC, and Zinc. These findings suggest that ICl-G1 is the result of expression of chloride channels related to ClC2. ICl-G2 currents show outward rectification and are dependent of intracellular calcium, its selectivity sequence is (Cl > Br > I > F) and are inhibited by NPPB, DIDS, SITS, 9AC, DPC, niflumic acid, tannic acid, and benzbromarone. These findings suggest that they are produced by calcium dependent chloride channels (CaCC). The third type of currents (ICl-G3) appears only after a hypoosmotic challenge, and has similar properties to those described for ICl-swell, such as outward rectification, instant activation, and slow inactivation at large depolarizing voltages. They were blocked by NPPB, DIDS, 9AC, NIf, DCPIB, and tamoxifen. Our results indicate that Giardia intestinalis has at least three types of anion conductances.

Safety of the treatment for voluntary pregnancy termination by gestational age. Medellín, Colombia, 2013-2014 / Seguridad del tratamiento de la interrupción voluntaria del embarazo según edad gestacional en medellín, colombia, 2013-2014

RESUMEN Objetivo: describir la seguridad del tratamiento médico-quirúrgico empleado en mujeres que acuden a interrupción voluntaria del embarazo. Materiales y métodos: cohorte histórica. Se incluyeron todas las mujeres embarazadas, hasta con 26 semanas de edad gestacional, a quienes se les dio tratamiento para interrupción voluntaria del embarazo en una institución de referencia en Medellín, Colombia, entre enero de 2013 y diciembre de 2014. Muestreo consecutivo. Se midieron las variables sociodemográficas obstétricas, los efectos no deseados y las complicaciones en el tratamiento de la interrupción voluntaria del embarazo. Se hizo análisis descriptivo. Resultados: se incluyeron 87 mujeres, la mediana de edad de las mujeres al momento de la interrupción fue de 24 años (rango intercuartílico [Rq] = 12), el 69,0 % estaban solteras y el 73,4 % desempleadas. La principal causa de interrupción fue el riesgo para la salud de la madre en el 61,0 %, seguido por antecedente de violencia sexual en el 26,4 % y malformaciones fetales en el 12,6 %; un total de 70 mujeres (80,4 %) tenía menos de 18 semanas de gestación y fueron tratadas con misoprostol más aspiración manual endouterina; 17 (19,6 %) tenían entre 18 y 26 semanas de gestación, las cuales recibieron misoprostol y legrado. El primer grupo (edad gestacional <18 semanas) no presentó complicaciones, solo efectos no deseados tales como dolor y vómito; el segundo grupo (> o igual a 18 semanas) presentó hemorragia en el 41 % de los casos. Conclusiones: el riesgo para la salud materna constituyó el principal motivo para la interrupción del embarazo. La interrupción del embarazo antes de la semana 18 es segura, entre las semanas 18 a 26, con misoprostol y legrado uterino, se acompañó de una alta frecuencia de hemorragia.

ABSTRACT Objective: To describe the safety of medical and surgical treatments used in women seeking voluntary pregnancy termination. Materials and Methods: Historical cohort of all pregnant women with up to 26 weeks of gestation who received treatment for voluntary pregnancy termination in a referral institution in Medellín, Colombia, between January 2013 and December 2014. Sampling was consecutive. Measured variables included sociodemographic and obstetric variables, undesired effects, and complications of the voluntary pregnancy termination treatment. A descriptive analysis was carried out. Results: Overall, 87 women were included. The mean age at the time of termination was 24 years (inter-quartile range [IQR] = 12), 69.0 % were single, and 73,4 % were unemployed. The main reason for termination was the risk to the mother's health in 61,0 % of cases, followed by a history of sexual violence in 26.4 % and fetal malformations in 12.6 %; a total of 70 women (80,4 %) had less than 18 weeks of gestation and were treated with misoprostol plus manual vacuum aspiration; 17 (19,6 %) had between 18 and 26 weeks of gestation and were treated with misoprostol followed by dilation and curettage. The first group (gestational age <18 weeks) experienced undesired effects such as pain and vomiting; in the second group (> or equal to 18 weeks), 41.0 % of the women experienced hemorrhage. Conclusions: The risk to the mother's health was the main reason for the termination of pregnancy. Termination before 18 weeks was found to be safe, while termination between 18 and 26 weeks using misoprostol and curettage was associated with a high frequency of hemorrhage.

Influence of Endogenous Cardiac Glycosides, Digoxin, and Marinobufagenin in the Physiology of Epithelial Cells.

Cardiac glycosides are a group of compounds widely known for their action in cardiac tissue, some of which have been found to be endogenously produced (ECG). We have previously studied the effect of ouabain, an endogenous cardiac glycoside, on the physiology of epithelial cells, and we have shown that in concentrations in the nanomolar range, it affects key properties of epithelial cells, such as tight junction, apical basolateral polarization, gap junctional intercellular communication (GJIC), and adherent junctions. In this work, we study the influence of digoxin and marinobufagenin, two other endogenously expressed cardiac glycosides, on GJIC as well as the degree of transepithelial tightness due to tight junction integrity (TJ). We evaluated GJIC by dye transfer assays and tight junction integrity by transepithelial electrical resistance (TER) measurements, as well as immunohistochemistry and western blot assays of expression of claudins 2 and 4. We found that both digoxin and marinobufagenin improve GJIC and significantly enhance the tightness of the tight junctions, as evaluated from TER measurements. Immunofluorescence assays show that both compounds promote enhanced basolateral localization of claudin-4 but not claudin 2, while densitometric analysis of western blot assays indicate a significantly increased expression of claudin 4. These changes, induced by digoxin and marinobufagenin on GJIC and TER, were not observed on MDCK-R, a modified MDCK cell line that has a genetically induced insensitive α1 subunit, indicating that Na-K-ATPase acts as a receptor mediating the actions of both ECG. Plus, the fact that the effect of both cardiac glycosides was suppressed by incubation with PP2, an inhibitor of c-Src kinase, PD98059, an inhibitor of mitogen extracellular kinase-1 and Y-27632, a selective inhibitor of ROCK, and a Rho-associated protein kinase, indicate altogether that the signaling pathways involved include c-Src and ERK1/2, as well as Rho-ROCK. These results widen and strengthen our general hypothesis that a very important physiological role of ECG is the control of the epithelial phenotype and the regulation of cell-cell contacts.

[Where internists work?]. / Dónde trabajan los internistas?

For health institutions, knowing the fate of human resources within their classrooms is an extremely complicated task. Within the Instituto Mexicano del Seguro Social, where most specialists are trained in our country, with a clear orientation towards the pursuit of excellence and satisfaction of their needs human resources for health in Mexico is provided, hence the need to identify the professional profile and career destination of its graduates, which will be useful in the training of human resources for health.

Para las instituciones de salud, conocer el destino de los recursos humanos que se forman dentro de sus aulas es una tarea complicada. Al interior del IMSS se imparte la mayoría de los cursos de formación de especialistas en México, con una orientación clara hacía la búsqueda de la excelencia y la satisfacción de sus necesidades de recursos humanos para la salud, de ahí la necesidad de identificar el perfil profesional y el destino de sus egresados, lo que resultará de utilidad en la formación de recursos humanos para la salud.

Valvuloplastia percutánea con balón de válvula mitral durante la gestación. Reporte de dos casos en un hospital de cuarto nivel de atención en Cali, Colombia y revisión de la literatura / Percutaneous balloon mitral valvuloplasty during pregnancy. Report of two cases in a level IV hospital in Cali, Colombia, and review of the literature

Objetivo: Describir la experiencia de dos casos de gestantes con estenosis mitral valvular, llevadas a valvuloplastia percutánea con balón y dilatación como alternativa terapéutica para contrarrestar los riesgos de colapso y deterioro materno-fetal y permitir la progresión del embarazo sin complicaciones cardiovasculares o el deterioro funcional, y realizar una revisión de la literatura publicada sobre la realización del procedimiento en gestantes. Materiales y métodos: Se presentan dos casos de estenosis mitral severa y compromiso funcional asociado, de aparición en el segundo trimestre del embarazo, atendidos en una institución de cuarto nivel de complejidad, centro de referencia regional. Se manejaron por medio de valvuloplastia mitral con balón, con desenlaces clínicos maternos perinatales favorables. La revisión de la literatura se hizo a partir de los términos: "valvuloplastia", "estenosis mitral" y "embarazo". Se realizó una búsqueda en la base de datos Medline vía PubMed, Medes y Scopus. Se excluyeron los procedimientos descritos que estaban dirigidos al reparo valvular del feto. Los estudios se centraron en los cambios en las mediciones de la válvula, los resultados obstétricos y la seguridad. Resultados: Se identificaron doce títulos. Los resultados obtenidos son comparables a los reportes de casos de estenosis de válvula mitral con procedimiento asistido por balón para dilatación de la válvula. En general, el procedimiento es exitoso, incrementa el área de la válvula mitral y reduce el gradiente de presión en la válvula. No obstante, existe el riesgo de desarrollar insuficiencia de válvula mitral tras la conducta, trombosis y muerte. Conclusión: La valvuloplastia percutánea con balón y dilatación como alternativa terapéutica es una opción por considerar en el manejo de la estenosis mitral en la gestante con deterioro de la clase funcional y el aumento durante el seguimiento de la presión en cuña pulmonar. Se requieren estudios controlados que validen los resultados de los estudios observacionales.

Objective: To describe the experience of two cases of pregnant women with mitral stenosis taken to percutaneous balloon valvuloplasty and dilatation as a therapeutic option to counteract the risk of collapse and maternal and foetal deterioration, and to allow progression of the gestation without cardiovascular complications or functional impairment; and to conduct a review of the published literature regarding this procedure in pregnant women. Materials and methods: Two cases of severe mitral stenosis and associated functional involvement of early onset during the second trimester of pregnancy, seen in a level IV regional referral centre. The two cases were managed with balloon mitral valvuloplasty, with favourable perinatal maternal outcomes. The review of the literature was done using the terms Valvulopasty, Mitral Stenosis and Pregnancy. A search was conducted in Medline via Pubmed and in the MEDES and SCOPUS databases. Procedures described for the performance of foetal valve repair were excluded. Studies were focused on the diagnostic findings and the course of the surgical procedure. Results: Overall, 12 titles were identified. The results obtained are comparable with the case reports found in the literature on mitral valve stenosis using balloon-assisted procedures for valve dilatation. In general terms, the procedure is successful, increasing the area of the mitral valve and reducing the pressure gradient across the valve. However, there is a risk of mitral regurgitation, thrombosis and death following the procedure. Conclusion: Percutaneous mitral valvuloplasty with balloon dilatation is a therapeutic option that may be considered for the management of mitral stenosis in pregnant women with functional class deterioration and increasing pulmonary wedge pressure during follow-up. Controlled studies are required in order to validate the results of observational studies.

Estandarización de marcadores moleculares microsatélites para su uso en la industria forestal de Misiones, Argentina / Standarization of microsatellite molecular markers for Misiones (Argentina) forest industry

Provincia de Misiones posee actualmente una actividad forestal en pujante crecimiento ubicóndose entre las primeras del pais. Este marco de desarrollo productivo permite predecir un ámbito de crecimiento favorecido por las nuevas condiciones del mercado internacional. Por otro lado a pesar del avance de la tecnologi­a industrial, no se ha alcanzado el nivel de desarrollo biotecnológico óptimo que conjugue la calidad genética con caracterí­sticas fenotópicas de excelencia en las especies maderables de mayor demanda en la Provincia basó¡ndose la selección en criterios netamente fenotópicos y en la experiencia del productor, sin contarse con métodos moleculares desarrollados en la región. Este trabajo presenta los resultados del Proyecto Federal de Innovacíon Productiva (PFIP Mi09) cuyo objetivo principal fue estandarizar y transferir al sector productivo un conjunto de marcadores moleculares microsalites para ser aplicado al análisis de poblaciones y forestaciones de Araucaria angustifolia y Pinus taeda provenientes de la Provincia de Misiones (Argentina). Esto permitirá conocer el perfil genético de plantaciones y poblaciones de estas especies forestales, pudiendo aplicarse a la certificación de calidad en la producción forestal o a la selección de ejemplares de especies nativas.

Misiones Province currently has the first intensive forestry activity of Argentine. This framework of productive development allows predict an area of growth favored by the new conditions of the international market. On the other side despite the progress of industrial technology, has not been reached the optimal level of biotechnological development that combining quality with genomic and phenotypic characteristics of forest species. This work presents the results of Federal Project of Productive Innovation (PFIP Mi09) whose main objective was standardize and transfer to the productive sector a set of microsatellites molecular markers to be applied to the populations analysis of Araucaria angustifolia and Pinus taeda forestation from the Misiones (Argentine). This will reveal the plantations and forest genetic profile and may be applied to genetic certification of forest production quality.