The yawning gap between osteoporosis diagnosis and treatment after a fragility fracture in Mexico.

This study shows a diagnostic and therapeutic gap for osteoporosis in patients with fragility fractures of the hip, distal radius, and vertebrae. Patients with fragility fractures treated in Mexico fail to receive an osteoporosis diagnosis, referral, and follow-up treatment. The therapeutic gap is higher than reported in other countries. INTRODUCTION: Osteoporosis is a highly prevalent and disabling disease. While there is typically a gap between osteoporosis diagnosis and treatment after a fragility fracture, this gap has not been measured in Mexico. The study aimed to describe and quantify the gap between osteoporosis diagnosis and treatment after an incident fragility fracture. MATERIALS AND METHODS: A descriptive and 3-year retrospective chart review study was conducted on patients over the age of 50 with a diagnosis of an incident acute low-energy fracture of either the hip, distal radius, or vertebrae. RESULTS: We included 838 patients with a mean age of 76.3 ± 12.2 years. The sample was mostly women (665 participants, 79.4%); 589 (70.3%) had a hip fracture, 173 (20.6%) had a distal radius fracture, and 76 (9.1%) had a vertebral fracture. Only 28 (3.3%) had a previous diagnosis and were taking a pharmacological treatment for osteoporosis; 11 (1.3%) received their diagnosis while hospitalized. Immediately after the fracture, and 1 and 3 years later, 144 (17.1%), 71 (8.4%), and 96 (11.4%) respectively received a pharmacological treatment, 195 (23.2%), 65 (7.7%), and 45 (5.3%) supplementation, and 16 (1.9%), 16 (1.9%), and 21 (2.5%) a non-pharmacologic treatment. No significant differences in treatment prescriptions were found after a second or third fracture. CONCLUSION: The study quantifies the too high frequency of failure to diagnose and treat osteoporosis in patients with fragility fractures. Measures should be established to reduce the yawning gap between osteoporosis diagnosis and treatment after a fragility fracture.

Estimation of absolute risk of fracture due to fragility in Mexican women with early and natural menopause.

BACKGROUND: Menopausal women lose until 5% of their bone density during the first years of menopause. One of 12 Mexican women will suffer a hip osteoporotic fracture after the age of 50. OBJECTIVE: To assess the absolute risk of major fracture (vertebrae, hip and forearm) and hip fracture and to establish the relation between years of menopause and bone mineral density (BMD). METHOD: A cross sectional analytical study, including women over 50 classified by early and natural menopause. Bone densitometry was performed and risk of fracture was calculated with FRAX (Fracture Risk Assessment Tool). RESULTS: From 209 women, 32% had early menopause and 68% had natural menopause. The average age were 67.4 ± 9.2 vs. 65.9 ± 8.3 years; they had 27.3 ± 9.4 vs. 15.2 ± 8.4 years of menopause (p ≤ 0.01); the hip BMD was 0.6286 ± 0.115 vs. 0.6789 ± 0.132 g/cm2 (p ≤ 0.05), with a T-score of -2.11 ± 0.979 vs -1.70 ± 1.129 (p ≤ 0.05), respectively. The 10 years risk probability for major fractures was 8.8 ± 4.7 vs. 7.4 ± 4.7 (p ≤ 0.05) and for hip fractures was 3.2 ± 3.0 vs. 2.5 ± 2.9 (p > 0.05). CONCLUSIONS: We recommend to take into account the clinical importance of the years of menopause and the type of menopause, as factors that influence the bone density decrease and the increase of future fractures risk.

ANTECEDENTES: La mujer pierde hasta un 5% de densidad ósea durante los primeros años de menopausia. En México, una de cada 12 mujeres tendrá una fractura de cadera por fragilidad después de los 50 años. OBJETIVO: Estimar el riesgo absoluto de fractura mayor (vertebrales, cadera y antebrazo) y de fractura de cadera, y establecer la relación entre los años de menopausia y la densidad mineral ósea (DMO). MÉTODO: Diseño transversal, analítico y comparativo. Se incluyeron mujeres mayores de 50 años, agrupadas en menopausia temprana y natural. Se realizó densitometría ósea y se calculó el riesgo de fractura con el FRAX (Fracture Risk Assessment Tool). RESULTADOS: Se estudiaron 209 mujeres, el 32% con menopausia temprana y el 68% con menopausia natural, de una edad promedio de 67.4 ± 9.2 y 65.9 ± 8.3 años, respectivamente, con 27.3 ± 9.4 y 15.2 ± 8.4 años (p ≤ 0.01) con menopausia. La DMO de cadera fue de 0.6286 ± 0.115 y 0.6789 ± 0.132 g/cm2 (p ≤ 0.05), y la T-score fue de −2.11 ± 0.979 y −1.70 ± 1.129, respectivamente (p ≤ 0.05). Las probabilidades de riesgo a 10 años para fracturas mayores fueron de 8.8 ± 4.7 y 7.4 ± 4.7 (p ≤ 0.05), y para fractura de cadera fueron de 3.2 ± 3.0 y 2.5 ± 2.9 (p > 0.05), respectivamente. CONCLUSIONES: Se recomienda considerar la importancia clínica de los años de menopausia y del tipo de menopausia como factores que influyen en la disminución de la DMO y elevan el riesgo para futuras fracturas.

Validación y confiabilidad del Cuestionario de Tamizaje Auditivo Escolar en adolescentes usuarios de reproductores de música comprimida.

INTRODUCCIÓN: El uso frecuente de reproductores de archivos de música y la intensidad del volumen son factores de riesgo para el desarrollo de hipoacusia. OBJETIVO: Validar el Cuestionario de Tamizaje Auditivo Escolar (CUTAE) para identificar alteraciones auditivas en adolescentes usuarios de reproductores de archivos música comprimida (RPAMC). MÉTODO: Se estudiaron adolescentes usuarios de RPAMC, sin hipoacusia ni patología de oído medio. Se aplicó el CUTAE y se realizó audiometría. Se determinó reproducibilidad (coeficiente correlación intraclase-CCI), consistencia interna (alfa de Cronbach), validez de apariencia (técnica Delphi), validez concurrente CUTAE-audiometría (correlación de Pearson) y validez predictiva (regresión múltiple) del cuestionario. RESULTADOS: Se evaluaron 59 adolescentes (118 oídos), 66 % del sexo femenino, con edad promedio fue de 13 años; 90 oídos con parámetros normales, 18 con umbral menor de 20 dB con morfología de trauma acústico (TA) en la frecuencia de 6 KHz y 10 con TA. El cuestionario tuvo CCI de 0.788, alfa de Cronbach de 0.807, correlación de Pearson de 0.290 a 0.368 (p < 0.05); las variables predictivas fueron horas de uso del dispositivo, dificultad para escuchar a las personas (p < 0.05) y tipo de zumbido (p = 0.07). CONCLUSIÓN: El CUTAE tiene propiedades clinimétricas para considerarlo una prueba de tamizaje en la detección de alteraciones auditivas en adolescentes usuarios de RPAMC. INTRODUCTION: Frequent use of audio file players and volume intensity are risk factors for the development of hypoacusis. OBJECTIVE: To validate the school-age hearing screening questionnaire (CUTAE, by its Spanish acronym) for hearing disorders detection in teenage users of compressed audio file players (CAFP). METHODS: Adolescent CAFP users without hypoacusis or middle ear pathology were studied. The CUTAE was applied and audiometry was carried out. Reproducibility (intraclass correlation coefficient-ICC), internal consistency (Cronbach's alpha), face validity (Delphi technique), CUTAE-audiometry concurrent validity (Pearson's correlation) and predictive validity (multiple regression) of the questionnaire was assessed. RESULTS: Fifty nine adolescents (118 ears), 66% females, average age of 13 years, were assessed. Ninety ears had normal parameters, 18 showed a threshold decrease < 20 dB, with morphology associated with acoustic trauma (AT) at 6 kHz and 10 with AT. The questionnaire had an ICC of 0.788, a Cronbach alpha-value of 0.807, Pearson's correlation values of 0.290 to 0.368 (p < 0.05); the predictive variables were usage hours, difficulty hearing others (p < 0.05) and type of buzzing (p = 0.07). CONCLUSION: The CUTAE has adequate clinimetric properties to be considered as a screening test in the detection of hearing disorders in adolescent users of CAFP.

Association of the IL6 rs1800796, but not of the IL6 rs1800795, IL6R rs4845617 and rs2228145 polymorphisms with hip fracture in elderly Mexican women.

BACKGROUND AND AIMS: Polymorphisms in Interleukin-6 (IL6) and its receptor (IL6R) have been associated with bone mineral density. In this work, the G-174C and G-572C polymorphisms in IL6, G-208A, and Asp358Ala in IL6R were analyzed in Mexican women with hip fracture. METHODS: Postmenopausal Mexican women (60 years or over) with hip fragility fracture (77.97 ± 8 years) and without hip fracture (70.5 ± 7.02 years) were genotyped by real-time PCR. RESULTS: The rs1800796 GG genotype was associated with low risk of fracture (p = 0.05), while GC genotype was associated with high risk of fracture [p = 0.047, OR 2.3 (95% CI 1.013-5.2)]. The AA genotype of the rs2228145 SNP (IL6R) was significantly different [p = 0.033, OR 1.94 (95% CI 1.01-3.75)], but when data were adjusted by age and body mass index, there were no differences (p = 0.9). CONCLUSION: Our results suggest that the IL6 rs1800796 SNP is a good marker for hip fracture risk in Mexican women.

[Assessment and intervention thresholds to detect cases at risk of osteoporosis and fragility fractures with FRAX® in a mexican population for the first level of healthcare]. / Umbrales de evaluación e intervención para la detección de casos en riesgo de osteoporosis (OP) y fracturas por fragilidad con FRAX® en población mexicana para el primer nivel de salud.

OBJECTIVE: To estimate the evaluation and intervention thresholds using FRAX® in Mexican population. METHODS: Probabilities for a mayor fracture using the Mexican FRAX® version to estimate the evaluation and intervention thresholds using clinical scenarios were obtained in both sexes 40 years and over. Projections for 2020 were done to estimate the number of patients at the intervention level taking the osteoporosis prevalence in Mexicans aged 50 years and over. RESULTS: The cutoffs for the intervention thresholds were 2.6%-20.0%. Individuals with thresholds above these probabilities are amenable for intervention. The assessment thresholds range from 1.2-3.2% to 12.5-24.4% for 40 to 90 years. According to projections of our population, approximately three million people are susceptible to intervention by 2020. CONCLUSION: The use of FRAX® thresholds of intervention and evaluation developed in this study will be useful in the primary care level for case detection at high risk of fragility fracture.

Health-related quality of life after surgery for hip fracture: a multicentric study in Mexican population.

INTRODUCTION: Hip fractures are an important cause of morbidity and mortality and one of the main causes of disability in the older population. The lifetime risk for any type of osteoporotic fracture is very high and falls within the range of 40–-50% in women and 13–-22% for men. In Mexico, the lifetime likelihood of having a hip fracture at 50 years of age is 8.5% in Mexican women and 3.8% in Mexican men, but this is expected to rise in upcoming years. AIM: This study aims to report the Health-Related Quality of Life over the first six months after a hip fracture in two public and two private tertiary care hospitals in Mexico City. METHOD: Changes over time were evaluated through visual observation of each patient’s development trajectory using the graphic representation of the EQ-5D global score. The trajectories were grouped by affinity into five levels of progress according to clinical course. The identified descriptive options were analyzed using the multinomial logistic regression model (LR). RESULTS: One-hundred-and-thirty-six (136) patients with a hip fracture were followed after surgery. Their mean age was 77 ± 10 years. During the first month, mobility, daily activities, and self-care were the most affected. The group aged between 80 and 84 years reported extreme problems regarding anxiety and depression (21%), and those aged between 50 and 74 years described having issues concerning pain and discomfort (27%). At the 6-month follow-up, only those aged > 85 years of age showed worsening of their condition, a high proportion of these ranking at level 3 in mobility, self-care, and anxiety/depression. Toward the end of the follow-up period, this last group reported having extreme problems (being unable to carry out everyday activities) and worsening of their mobility (9.2%) (inability to walk about) (LR test, p = 0.06). DISCUSSION: Patients with hip fracture showed difficulties in different areas during the first month after surgery, with steady recuperation up to month six. Age was an important factor in the recovery of all evaluated domains. This graphical tool facilitates classification, identification, and monitoring Health-Related Quality of Life in patients with hip fractures.

INTRODUCCIÓN: Las fracturas de cadera son una importante causa de morbilidad, mortalidad y una de las principales causas de discapacidad en poblaciones adultas. El riesgo en el tiempo de vida de tener una fractura por osteoporosis es muy alto, se encuentra en un rango entre 40 y 50% en mujeres y desde 13 hasta 22% para los hombres. En México la probabilidad de tener una fractura de cadera a los 50 años de edad fue de 8,5% en mujeres y 3,8% en varones, pero irán aumentando en los próximos años. OBJETIVO: El objetivo del estudio es reportar la calidad de vida relacionada con la salud durante los primeros seis meses después de una fractura de cadera, en dos hospitales públicos y dos hospitales privados de tercer nivel de atención en Ciudad de México. MÉTODO: Se evalúan los cambios en el tiempo por medio de la observación visual del desarrollo de trayectorias de cada paciente. Esta información se representa en forma gráfica usando el puntaje global del EQ-5D. Las trayectorias fueron agrupadas por afinidad en cinco niveles de progreso de acuerdo a su evolución clínica. Las opciones descriptivas identificadas se analizaron usando un modelo de regresión logística multinomial. RESULTADOS: Después de una cirugía se siguieron a 136 pacientes con fractura de cadera, cuyo promedio de edad fue de 77 ± 10 años. Durante el primer mes la movilidad, actividades de la vida diaria y cuidado de sí mismo fueron los aspectos más afectados. El grupo de edad entre 80 hasta 84 años reportó problemas extremos, presentando ansiedad y depresión en el 21% de los casos. Las personas de 50 a 74 años describieron tener dolor y malestar (27%). A los seis meses de seguimiento sólo los mayores de 85 años mostraron un deterioro de su condición. Una alta proporción de ellos se clasifican en el nivel 3 en movilidad, cuidado personal y ansiedad/depresión. Hacia el final, este último grupo informó tener problemas extremos como la incapacidad de llevar a cabo las actividades cotidianas, y la disminución de su movilidad con 9,2% en la incapacidad para caminar (prueba regresión logística multinomial, p = 0,06). DISCUSIÓN: Los pacientes con fractura de cadera mostraron dificultades en diferentes áreas durante el primer mes después de la cirugía, con una recuperación constante hasta los seis meses. La edad fue un factor importante en la recuperación de todos los dominios evaluados. Esta herramienta gráfica facilita la clasificación, identificación y monitoreo de la calidad de vida relacionada con la salud en pacientes con fractura de cadera.

Seguimiento de la calidad de vida relacionada con la salud después de una cirugía de fractura de cadera: estudio multicéntrico en población mexicana / Health-related quality of life after surgery for hip fracture: a multicentric study in Mexican population

Introducción Las fracturas de cadera son una importante causa de morbilidad, mortalidad y una de las principales causas de discapacidad en poblaciones adultas. El riesgo en el tiempo de vida de tener una fractura por osteoporosis es muy alto, se encuentra en un rango entre 40 y 50 por ciento en mujeres y desde 13 hasta 22 por ciento para los hombres. En México la probabilidad de tener una fractura de cadera a los 50 años de edad fue de 8,5 por ciento en mujeres y 3,8 por ciento en varones, pero irán aumentando en los próximos años. Objetivo El objetivo del estudio es reportar la calidad de vida relacionada con la salud durante los primeros seis meses después de una fractura de cadera, en dos hospitales públicos y dos hospitales privados de tercer nivel de atención en Ciudad de México. Método Se evalúan los cambios en el tiempo por medio de la observación visual del desarrollo de trayectorias de cada paciente. Esta información se representa en forma gráfica usando el puntaje global del EQ-5D. Las trayectorias fueron agrupadas por afinidad en cinco niveles de progreso de acuerdo a su evolución clínica. Las opciones descriptivas identificadas se analizaron usando un modelo de regresión logística multinomial. Resultados Después de una cirugía se siguieron a 136 pacientes con fractura de cadera, cuyo promedio de edad fue de 77 +/- 10 años. Durante el primer mes la movilidad, actividades de la vida diaria y cuidado de sí mismo fueron los aspectos más afectados. El grupo de edad entre 80 hasta 84 años reportó problemas extremos, presentando ansiedad y depresión en el 21 por ciento de los casos. Las personas de 50 a 74 años describieron tener dolor y malestar (27 por ciento). A los seis meses de seguimiento sólo los mayores de 85 años mostraron un deterioro de su condición. Una alta proporción de ellos se clasifican en el nivel 3 en movilidad, cuidado personal y ansiedad/depresión

Introduction Hip fractures are an important cause of morbidity and mortality and one of the main causes of disability in the older population. The lifetime risk for any type of osteoporotic fracture is very high and falls within the range of 40–50 percent in women and 13–22 percent for men. In Mexico, the lifetime likelihood of having a hip fracture at 50 years of age is 8.5 percent in Mexican women and 3.8 percent in Mexican men, but this is expected to rise in upcoming years. Aim This study aims to report the Health-Related Quality of Life over the first six months after a hip fracture in two public and two private tertiary care hospitals in Mexico City. Method Changes over time were evaluated through visual observation of each patient’s development trajectory using the graphic representation of the EQ-5D global score. The trajectories were grouped by affinity into five levels of progress according to clinical course. The identified descriptive options were analyzed using the multinomial logistic regression model (LR). Results One-hundred-and-thirty-six (136) patients with a hip fracture were followed after surgery. Their mean age was 77 +/- 10 years. During the first month, mobility, daily activities, and self-care were the most affected. The group aged between 80 and 84 years reported extreme problems regarding anxiety and depression (21 percent), and those aged between 50 and 74 years described having issues concerning pain and discomfort (27 percent). At the 6-month follow-up, only those aged > 85 years of age showed worsening of their condition, a high proportion of these ranking at level 3 in mobility, self-care, and anxiety/depression. Toward the end of the follow-up period, this last group reported having extreme problems (being unable to carry out everyday activities) and worsening of their mobility (9.2 percent (inability to walk about) (LR test, p = 0.06

Impact of osteoporosis-associated vertebral fractures on health-related quality of life in the Mexican population.

OBJECTIVE: To measure the impact on the health-related quality of life (HRQoL) of a sample of Mexicans with vertebral fractures. MATERIAL AND METHODS: One hundred fifteen subjects with vertebral fractures were interviewed and compared with 135 subjects similar in age without the fracture. Subjects were men and women > 50 years of age with osteoporosis confirmed by bone mineral densitometry and with at least 1 vertebral fracture verified by vertebral morphometry and Xrays. The sample was recruited from two sources: The Clínica de Osteoporosis at the Instituto Nacional de Rehabilitación and a random sample from the Latin American Osteoporosis Study. The Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) validated in Spanish for the Mexican population was applied. Descriptive statistics were used for demographic and clinical aspects of the sample, as well as χ2 for categorical variables and Student t test for independent samples for continuous variables. A multiple linear regression (LR) was conducted to characterize predictive variables related to quality of life. RESULTS: Two hundred fifty subjects were interviewed; 64% of them were women. The average age of those interviewed was 73.4 ± 11.4 years; 46% of the sample had vertebral fractures; of them 43% of were lumbar and 57% thoracic; the most frequent site was L1-T12. Significant changes were found in the group with fractures in pain, physical function, social function, and mental function (p < 0.05); in women, pain and social function were different between groups (p < 0.05); and those over 70 years also presented differences in physical, social, and mental function (p < 0.05); differences were found associated with the place of recruitment being worse in their quality of life those coming from the Clínica de Osteoporosis. Two or more fractures, age, being female and widowed were significant predictors for greater deterioration of HRQoL with the LR. CONCLUSION: This is the first study looking at the HRQoL in osteoporosis related fractures in Mexicans were quality of life deterioration on physical, social, and emotional functioning was demonstrated in subjects with two vertebral fractures. Age is a determining factor for greater deterioration in all studied domains. Differences between the samples obtained at the Clínica de Osteoporosis at the Instituto Nacional de Rehabilitación and the random population exemplifying that asymptomatic fractures are common and not diagnosed. It is important to scrutinize vertebral fractures at the first level because their timely detection allows for their evaluation and treatment and diminishes the probability of a second fracture. Our results can be generalized to men and women over 50 who live in the central megalopolis and in other states of the Valley of México.

Epidemiology of bone tumors in Mexico City: retrospective clinicopathologic study of 566 patients at a referral institution.

A retrospective analysis of all bone tumors accessioned at a large referral center (Instituto Nacional de Rehabilitacion) in Mexico City between 2000 and 2005 is presented. A total of 6216 biopsies and surgical resection specimens were reviewed during this period, of which 566 corresponded to bone tumors. Benign bone tumors accounted for 71.6% of cases and malignant bone tumors for 28.4%. The tumors affected men in 53.7% of cases and women in 46.3% of cases, with an average age at presentation of 25 years. The femur was the most common location of the tumors (39.9%), followed by the tibia (17.7%) and humerus (11.8%). The commonest malignant bone tumors were osteosarcoma (46.6%) and chondrosarcoma (8.7%). Of malignant bone tumors, 18.6% corresponded to metastases of carcinomas from internal organs and 8.1% were multiple myeloma. The most common benign bone tumor was osteochondroma (43.7%) followed by giant cell tumor of bone (14.6%) and enchondroma (10.1%). The age distribution showed a peak in children and adolescents comprised predominantly of benign lesions and a second peak in young adults that corresponded to malignant bone tumors (principally osteosarcoma). Malignant bone tumors most often involved the femur, vertebra, and tibia. Our results parallel the findings previously reported in the world literature and show a similar distribution and epidemiology as in other developed and underdeveloped countries. Geographic location does not appear to represent a risk factor for any particular type of bone tumor and does not affect the age distribution, location, or histopathologic type of the lesions.

Cultural adaptation and validation of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) in a Mexican population.

Measuring quality of life (QOL) is important, but to date, questionnaires to measure QOL in Mexican patients with osteoporosis (OP) have not been validated. A study was carried out to culturally adapt and validate the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) in a Mexican population. Interviews were performed with 160 women, 80 patients with at least one vertebral fracture, and 80 patients with OP as determined by the World Health Organization criteria. Several cultural modifications were made to the Spanish version of the QUALEFFO. Content validity was assessed by a group of experts, and a pilot study was undertaken. At the same time, the Spanish version of the Short Form 36 (Medical Outcomes Study) was applied. The mean age of patients was 71.9 +/- 11.1. The QOL questionnaire showed a test-retest reproducibility (R (i) = 0.94) and internal consistency (alpha = 0.92), while social function scored low (alpha = 0.46). Concurrent validity was significant (r = -0.837, p < 0.001). Significant differences were found between the two groups for pain (p < 0.05), physical function (p < 0.01), social function (p < 0.01), mental function (p < 0.05), and number of fractures (p < 0.001). Discriminatory characteristics between the groups were significant for physical (p < 0.001), social (p < 0.001), and mental (p < 0.02) function. The cultural adaptation of the QUALEFFO was consistent, homogenous, and discriminative. It also showed deterioration in the QOL group of Mexicans with vertebral fractures. The QUALEFFO can be used in a Mexican population to measure the QOL in patients with vertebral fractures after some cultural modifications to take into account local sensibilities.

Rehabilitación en fracturas del tercio medio de clavícula operadas con clavo Hunec / Rehabilitation of clavicle fractures after surgical treatment by Hunec intramedullary pinning

Las fracturas de clavícula del tercio medio de la clavícula tratadas con clavo Hunec pueden iniciar la rehabilitación inmediatamente después de la cirugía, por que es un implante que permite la movilidad articular del hombro, por lo tanto fortalecimiento inmediato. Se estudiaron 35 pacientes, con edad promedio de 29 años, 30 masculinos (86 por ciento) y 5 femeninos (14 por ciento), la ocupación de mayor porcentaje fue el hogar 15 por ciento y estudiante 29 por ciento. Los arcos de movilidad fueron completos y la fuerza muscular normal. La integración de las actividades de la vida diaria 3 días (56 por ciento) y laboral en 15 a 20 días, posterior a la cirugía. Prueba t de Student p<0.05 para arcos de movilidad y fuerza muscular. Discusión. La rehabilitación inicia con la selección del implante de acuerdo a la clasificación de las fracturas ya que permite hacer un programa de atención, que logre integrar al paciente a su vida laboral tempranamente. Conclusión. El clavo Hunec en las fracturas de clavícula permite integrar a las actividades de la vida diaria y de trabajo antes de 20 días