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OBJECTIVE: Validations of brief delirium tools have not included analysis of psychiatric disorders comorbidities or control groups. We validated the Delirium Diagnostic Tool-Provisional (DDT-Pro) in 422 geriatric inpatients with high incidence of depression and/or dementia. METHODS: Cross-sectional study using two delirium reference standards, DSM-5-TR and Delirium Rating Scale-Revised-98 (DRS-R98). We assessed concurrent and construct DDT-Pro validity too. RESULTS: There were 117 (27.7%) delirium cases using DDT-Pro, 104 (24.6%) per DSM-5-TR and 93 (22.0%) per DRS-R98; 133 patients (31.5%) had depression and 105 (24.9%) dementia, some comorbid with delirium. DDT-Pro accuracy (AUC under ROC curve) ranges were 88.3-95.9% vs DSM-5-TR and 92.7-95.0% vs DRS-R98 for whole sample and four diagnostic groups, without statistical differences. DDT-Pro ≤6 had the most balanced sensitivity-specificity for delirium diagnosis against both DSM-5-TR and DRS-R98 with similar specificity but higher sensitivity for DRS-R98 than DSM-5-TR delirium, with the highest values in patients with depression and dementia (≥92% sensitivity, ≥81% specificity). Positive and negative likelihood ratios support diagnostic strength. Concurrent validity was high reflected by significant correlations (p < 0.001) of DDT-Pro total and item scores with DRS-R98 and Delirium Frontal Index scores, highest in groups with comorbid depression and/or dementia. The DDT-Pro represented a single construct for delirium demonstrated by one factor with high item loadings and high internal consistency reliability of its items. CONCLUSIONS: The DDT-Pro demonstrated strong performance metrics in general hospital elderly inpatients with preexisting depression and/or dementia, which is unique among brief delirium tools. Its optimized cutoff score was the same as in other populations.

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OBJECTIVE: The investigators aimed to identify the clinical characteristics of patients with or without delirium and preexisting depression, dementia, both, or neither by using validated tools easily administered in clinical practice. METHODS: In this cross-sectional prospective observational study conducted in Medellín, Colombia, 200 geriatric inpatients were evaluated with the Delirium Diagnostic Tool-Provisional (DDT-Pro), Informant Questionnaire on Cognitive Decline in the Elderly, Hachinski Ischemic Scale, Cornell Scale for Depression in Dementia, and Charlson Comorbidity Index-short form. Delirium motor subtype, mortality, and length of hospital stay were assessed. RESULTS: The study included 134 patients without delirium (67%), 14 with delirium only (7%), 16 with delirium and dementia (8%), 13 with delirium and depression (7%), and 23 with delirium, dementia, and depression (the three Ds) (12%). Prevalence rates of dementia (59%) and depression (55%) among 66 patients with delirium were higher than prevalence rates among patients without delirium (13% and 28%, respectively), suggesting that both conditions are risk factors. Main medical diagnoses, mortality, and dementia type did not differ among groups. Motor subtypes were similar among delirium groups. Patients in the delirium groups, except those in the delirium and depression group, were older than patients without delirium. Medical burden was highest among the patients with delirium and dementia and those with all three conditions. Delirium and dementia were more severe when comorbid with each other. Depression was most severe among patients with delirium and depression. Patients with all three conditions had a longer length of hospital stay than those without delirium. CONCLUSIONS: Using brief tools to detect dementia and depression in conjunction with the DDT-Pro to assess delirium diagnosis and severity is feasible and enables a more in-depth evaluation of elderly hospitalized patients. Because previous longitudinal research suggests that these comorbid conditions influence prognosis following a delirium episode, better identification of the three Ds offers proactive interventional opportunities. Depression is an underrecognized risk factor for delirium.

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Terpenes are a major class of secondary metabolites present in all plants, and long hypothesized to have diversified in response to specific plant-herbivore interactions. Herbivory is a major biotic interaction that plays out across broad temporal and spatial scales that vary dramatically in temperature regimes, both due to climatic variation across geographic locations as well as the effect of seasonality. In addition, there is an emerging understanding that global climate change will continue to alter the temperature regimes of nearly every habitat on Earth over the coming centuries. Regardless of source, variation in temperature may influence herbivory, in particular via changes in the efficacy and impacts of plant defensive chemistry. This study aims to characterize temperature-driven variation in toxicological effects across several structural classes of terpenes in the model herbivore Vanessa cardui, the painted lady butterfly. We observed a general increase in monoterpene toxicity to larvae, pupa, and adults at higher temperatures, as well as an increase in development time as terpene concentration increased. Results obtained from this study yield insights into possible drivers of seasonal variation in plant terpene production as well as inform effects of rising global temperatures on plant-insect interactions. In the context of other known effects of climate change on plant-herbivore interactions like carbon fertilization and compensatory feeding, temperature-driven changes in plant chemical defense efficacy may further complicate the prediction of climate change impacts on the fundamental ecological process of herbivory.

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INTRODUCTION: Head and neck cancer (HNC) is the seventh most common type of cancer in the world. In Latin America, data on HCN are limited by the scarcity of population-based cancer registries. OBJECTIVE: To describe survival and changes in the time trends of incidence and mortality rates of HCN with data from the Cali Cancer Population Registry (Colombia) during 1962-2018. METHOD: Males and females of any age residing in Cali were included. The trends in incidence rates (1962-2016) and mortality (1984-2018) were analysed by calculating the mean annual percentage change (APC). Five-year net survival was estimated for the four 5-year periods of 1996-2015 using the Pohar-Perme method. RESULTS: During 1962-2015, 5,110 new cases of HNC were recorded: 1,506 in the larynx, 1,377 in the oral cavity, 487 in the nose and paranasal sinuses, 643 in the oropharynx, 603 in the salivary glands and 360 in Naso-Hypopharynx region. The incidence rates of HNC decreased significantly at all subsites, except in those associated with the human papillomavirus. Between 1984 and 2018, there were 1,941 deaths attributed to HNC, and the mortality rate decreased significantly. The 5-year age-standardized net survival was 43.2% in 1996-2000, remained stable during the following decade, and for 2011-2015 it was 50.9%. CONCLUSION: The incidence and mortality of HNC in Cali decreased significantly during the study period in both sexes.

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Background: Although previous cohort studies of women with multiple sclerosis (MS) yielded a reduction in relapse rate during pregnancy, the effect size has not been quantified in a comprehensive manner. In addition, the effects on disability progression and peripartum outcomes have been controversial. The purpose of this work is to assess the effect of pregnancy on disease activity, and to assess the effects of MS on pregnancy as well. Materials & methods: We searched in PubMed, Cochrane Library and EMBASE for cohort studies dealing with the effects of pregnancy on relapse rates, disability progression and peripartum outcomes in women with MS. The evaluated outcomes were: changes in the annualized relapse rate (ARR) in pregnancy and puerperium, disability worsening compared with the year before pregnancy, and peripartum outcomes, which were compared with the ones of non-MS women. In the majority of cohorts included here, the women were not under disease modifying therapies during pregnancy. Results: We found 23 cohort studies measuring changes in the ARR during pregnancy and puerperium; 12 were prospective and 11 retrospective. In 17 cohorts there was significant reduction in the ARR during pregnancy compared with prepregnancy period. The pooled mean reduction in the ARR was -0.5 (95% CI: 0.67-0.38), p < 0.001, from 15 cohorts included in meta-analysis. In 18 cohorts the ARR increased in the 3-month puerperium relative to prepregnancy year period; the pooled mean increase in the ARR was 0.22 (95% CI: 0.11-0.33), p < 0.001, from 14 cohorts included in meta-analysis. Disability worsening was addressed in 18 cohorts, and in 14 of them there were no significant changes. Peripartum complications and obstetrical outcomes were assessed in 16 cohorts, of whom 13 were retrospective, without finding significant differences. Conclusion: Pregnancy is associated with lower disease activity, and puerperium with higher disease activity. Disability does not change significantly after pregnancy. The obstetrical outcomes are not very different from those of non-MS women in most cohorts.

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Introducción: El cáncer es una enfermedad de alta incidencia, con múltiples factores etiológicos y diferentes características evolutivas. Objetivo: Describir la supervivencia y la tendencia de las tasas de incidencia y mortalidad por cáncer de laringe y senos paranasales en Cali (Colombia) durante el periodo 1962 a 2015. Diseño: Estudio observacional descriptivo. Métodos: La información de incidencia, durante el periodo 1962 a 2012, se obtuvo en el RPCC y la mortalidad entre 1984-2015 de la SSPM. El comportamiento de la tendencia se evaluó con el porcentaje de cambio anual (APC) y la supervivencia relativa se estimó con el método de Ederer II. La estadificación se realizó con la AJCC. Resultados: Durante 1962 a 2012, se diagnosticaron 1623 casos nuevos de cáncer, 85.2% (1383 casos) fueron de laringe y 14.8% (240 casos) sinunasal 76% fueron hombres y el CCE fue el tipo histológico más frecuente 84.1% y 59.6% en laringe y sinunasal respectivamente. Se observó una disminución significativa del riesgo de cáncer de laringe en ambos sexos, siendo mayor la disminución en hombres (APC=-1,1*(ICD95%: -1,6; -0,7)). La disminución en la tasa de incidencia de cáncer de laringe CEC fue mayor en hombres (APC=-1,1*(ICD95%: -1,6; -0,6)) durante 1962-2012. Las tasas de mortalidad disminuyeron significativamente (APC=- 2,5*(ICD95%:-3,6 -1,5)). La supervivencia relativa a 5 años durante el periodo 2008- 2012, 43,5%; 93 pacientes se estadificaron con supervivencia: T3-T4 (41,5%) y T1- T2 (55,0%). Conclusiones: El riesgo del cáncer de laringe y sinunasal escamocelular asociado al tabaquismo disminuyó de manera significativa en hombres y mujeres de Cali durante los últimos 53 años.

Introduction: Cancer is disease with high incidence, multiple etiological factors and different characteristics. Objective: To describe the survival and trend of the incidence and mortality rates for cancer of the larynx and paranasal sinuses in Cali (Colombia) during the period 1962 to 2015. Design: Descriptive observational study. Methods: Incidence information, during the period 1962 to 2012, was obtained in the RPCC and mortality between 1984-2015 of the SSPM. The behavior of the trend was evaluated with the percentage of annual change (APC) and the relative survival was estimated with the method of Ederer II. The arrangement was made with the AJCC. Results: During 1962 to 2012, 1623 new cases of cancer were diagnosed, 85.2% (1383 cases) were laryngeal and 14.8% (240 cases) sinunasal 76% were men and the CCE was the most frequent histological type 84.1% and 59.6% in larynx and sinunasal respectively. A significant decrease in the risk of laryngeal cancer was observed in both sexes, with a greater decrease in men (APC = -1.1 * (ICD95%: -1.6, -0.7)). The decrease in the incidence rate of laryngeal cancer CEC was higher in men (APC = -1.1 * (ICD95%: -1.6, -0.6)) during 1962-2012. Mortality rates decreased significantly (APC = -2.5 * (ICD95%: - 3.6 -1.5)). The 5-year relative survival rate during the period 2008-2012 was 43.5%; 93 patients were stratified with survival: T3-T4 (41.5%) and T1-T2 (55.0%). Conclusions: The risk of laryngeal and squamous cell sinonasal cancer associated to smoking decreased significantly in men and women of Cali during the last 53 years.

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PURPOSE: The purpose of this study is to describe the clinical characteristics of patients diagnosed with renal trauma at Hospital Universitario Del Valle (HUV) in Cali, Colombia. MATERIAL AND METHODS: This is a descriptive study of patients diagnosed with renal trauma (ICD 10) at HUV between 1 January 2003 and 31 December 2007. We gathered such variables as age, sex, haemodynamic stability, type of trauma, location and effect of injury, clinical examination findings at admission, presence of renal failure, need for transfusion, diagnostic method, accompanying injuries, required treatment, duration of hospital stay and complications. Statistical analysis was performed using SPSS v. 15. RESULTS: 106 patients were evaluated, 78.3% of whom were male; mean age was 30.5 years. The majority were admitted for blunt trauma (73.6%) mainly due to motorcycle accidents and falls from heights. Minor trauma (Grades 1-3) was found in 77.3% of cases, haematuria in 90% and flank pain in 64%. A CT scan was used in 69.8% of all cases. Conservative treatment was employed in 77.4% of the cases, mainly for minor trauma (P < .0001); of these, 12% subsequently required surgery. Acute abdominal pain was the main surgical indication. Procedures were as follows: Nephropexy (32%) nephrectomy (38%) and conservative treatment (26%). The main complication was rebleeding (3.8%). CONCLUSIONS: Minor trauma is the most frequent kind of kidney injury, and is usually present with associated injuries. Conservative treatment was administered to most patients, but the failure rate was 12% and the frequency of overall complications was 10%.

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Objetivo: Describir las características clínicas de los pacientes con diagnóstico de traumatismo renal en el Hospital Universitario del Valle (HUV) en Cali, Colombia. Materiales y métodos: Se realizó un estudio descriptivo de pacientes con diagnóstico de traumatismo renal (CIE 10) en el HUV entre el 1 de enero de 2003 y el 31 de diciembre de 2007. Se recolectaron variables como: edad, sexo, estabilidad hemodinámica, tipo de traumatismo, sitio y mecanismo de la lesión, hallazgos al examen físico de ingreso, fallo renal, requerimiento de transfusión, método del diagnóstico, lesiones asociadas, manejo del traumatismo, tiempo de hospitalización y complicaciones. El análisis estadístico se realizó en SPSS v. 15.Resultados: Se evaluó a 106 pacientes, el 78,3% varones, con un promedio de edad de 30años. La mayoría ingresó por traumatismo cerrado (73,6%), principalmente por accidente en moto y caídas de altura. Se encontró traumatismo menor (grado 1-3) en el 77,3% de los casos, hematuria (90%) y dolor en el flanco (64%). La tomografía computarizada se utilizó en el 69,8% de los casos. Se realizó un manejo conservador (77,4%) principalmente en traumatismo menor (p < 0,0001); de éstos un 12% requirió cirugía posteriormente. El abdomen agudo fue la indicación quirúrgica más frecuente. Se realizó: nefrorrafia (32%), nefrectomía (38%) y manejo conservador (26%). La complicación más frecuente fue el resangrado (3,8%).Conclusiones: El traumatismo renal menor es más frecuente y usualmente se presenta con lesiones asociadas. Se hace un manejo conservador en la mayoría de los pacientes; sin embargo, la tasa de fallo es del 12% y la frecuencia de complicaciones es del 10% (AU)

Purpose: The purpose of this study is to describe the clinical characteristics of patients diagnosed with renal trauma at Hospital Universitario Del Valle (HUV) in Cali, Colombia. Material and methods: This is a descriptive study of patients diagnosed with renal trauma (ICD 10) at HUV between 1 January 2003 and 31 December 2007. We gathered such variables as age, sex, haemodynamic stability, type of trauma, location and effect of injury, clinical examination findings at admission, presence of renal failure, need for transfusion, diagnostic method, accompanying injuries, required treatment, duration of hospital stay and complications. Statistical analysis was performed using SPSS v. 15.Results: 106 patients were evaluated, 78.3% of whom were male; mean age was 30.5 years. The majority were admitted for blunt trauma (73.6%) mainly due to motorcycle accidents and falls from heights. Minor trauma (Grades 1-3) was found in 77.3% of cases, haematuria in 90% and flank pain in 64%. A CT scan was used in 69.8% of all cases. Conservative treatment was employed in 77.4% of the cases, mainly for minor trauma (P <0.0001); of these, 12% subsequently required surgery. Acute abdominal pain was the main surgical indication. Procedures were as follows: Nephropexy (32%) nephrectomy (38%) and conservative treatment (26%). The main complication was rebleeding (3.8%).Conclusions: Minor trauma is the most frequent kind of kidney injury, and is usually present with associated injuries. Conservative treatment was administered to most patients, but the failure rate was 12% and the frequency of overall complications was 10% (AU)

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Introducción: la gastrosquisis es una malformación congénita de la pared abdominal, cuya prevalencía ha aumentado notablemente en varios países, por lo que conviene estudiarla en diferentes centros pediátricos. Objetivos: definir las características epidemiológicas y clínicas de los recién nacidos con gastrosquisis en la Unidad de Cuidados Intensivos Neonatales del Hospital Universitario del Valle (Cali, Colombia). Métodos: se hizo un estudio de tipo descriptivo-retrospectivo en el que se incluyeron 29 de los 35 recién nacidos con diagnóstico clínico de gastrosquisis, atendidos en la Unidad entre el 1 de enero de 2000 y el 31 de diciembre de 2004. Resultados: el promedio de edad materna fue de 18,8 años, 20 madres (69,0%) eran menores de 24 años y 22 (75,9%), primigestantes. El estudio incluyó a 16 niñas (55,2%) y 13 niños (44,8%). Quince (51,7%) nacieron por cesárea y 14 (48,3%), por vía vaginal. Doce (41,4%) nacieron a término y 17 (58,6%) fueron pretérmino. Diecinueve (65,5%) tuvieron peso bajo al nacer. En 10 casos (34,5%) el diagnóstico fue prenatal. El promedio del diámetro del defecto –registrado en 19 casos– fue 4,28 cm. Hubo malformaciones asociadas en 16 pacientes (55,2%), en 12 de ellos gastrointestinales. Diez (66,6%) de los 15 niños nacidos por cesárea tuvieron otras malformaciones. Sufrieron complicaciones 28 niños (96,6%), principalmente sepsis (23 casos) y murieron 10 (34,5%), ocho de ellos en choque séptico. Conclusiones: en este estudio predominaron la edad materna menor de 20 años y la primigestación. La principal causa de morbilidad fue la sepsis; se encontraron diferencias en la tasa de mortalidad según la procedencia, pues fue mayor en los niños remitidos de municipios diferentes a Cali. La distancia entre el sitio de procedencia y por ende el tiempo requerido para llegar a la UCI pueden estar asociados con la probabilidad de morir, pero el número de casos es pequeño para sacar conclusiones definitivas al respecto. La tasa de mortalidad de niños con gastrosquisis encontrada en este estudio fue similar a la informada en otros hospitales latinoamericanos, pero excedió a la reportada en hospitales de países desarrollados.

Introduction: Gastroschisis is a congenital malformation of the abdominal wall. It is convenient to study it in different pediatric centers because its prevalence rate has markedly increased in several countries. Objectives: To define the epidemiological and clinical characteristics of a group of newborn infants with gastroschisis. Methods: A descriptive-retrospective study was carried out between January 1, 2000, and December 31, 2004. It included 29 of the 35 newborn infants with gastroschisis treated at the Neonatal Intensive Care Unit, Hospital Universitario del Valle, in Cali, Colombia. Results: Average maternal age was 18.8 years. Twenty of the mothers (69.0%) were younger than 20 years, and 22 (75.9%) were primiparae. The study included 16 girls (55.2%) and 13 boys (44.8%). Fifteen infants (51.7%) were born by caesarean section and 14 (48.3%), by natural birth. Twelve (41.4%) were born at term and 17 (58.6%) were preterm babies. Nineteen (65.5%) had low birth weight. In 10 cases (34.5%) the diagnosis of gastroschisis was prenatally established. Average diameter of the defect (registered in 19 cases) was 4.28 cm. There were associated malformations in 16 patients (55.2%), 12 of which were of the gastrointestinal tract. Ten (66.6%) of the 15 infants born by caesarean section had associated malformations. Complications occurred in 28 infants(96.6%), mostly sepsis (23 cases). Ten infants (34.5%) died, 8 of them in septic shock. Conclusions: Maternal age under 20 years and primiparous women predominated in this study. The main morbidity cause was sepsis. Differences in the mortality rate were found according to the place of origin of the patients: it was higher in those referred from towns different from Cali. Distance and, consequently, the time required for reaching the ICU may have been associated with the probability of death; however, the small number of cases does not allow definitive conclusions in this respect. The death rate found in our study was similar to that reported from other Latin American hospitals for similar patients, but exceeded the one from institutions in developed countries.

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Some of the recurring themes seen on health-sector reform agendas of Western countries (those at the center as well as those on the periphery) over the last decade have been: the debate over new ways of organizing health systems, with sights set on achieving greater efficiency and quality; redefining health care benefit packages and services to better distribute health resources; and incorporating market mechanisms into the health care environment to better respond to expectations of health care consumers. The fundamental purpose of this article is to analyze certain concepts that define and explain the origin of the 1990s health care reforms in Latin America and to refute some of the more important principles, such as: the belief that improving the functional efficiency of the health care system alone would improve the health of the population; the excessive concern with the administrative and structural aspects of health systems without a discussion of the underlying theoretical models; the idea that access, in and of itself, can guarantee "equity in health"; and lastly, the undo emphasis that was placed on individual "risk factors" as the cause of all illness.

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Some of the recurring themes seen on health-sector reform agendas of Western countries (those at the center as well as those on the periphery) over the last decade have been: the debate over new ways of organizing health systems, with sights set on achieving greater efficiency and quality; redefining health care benefit packages and services to better distribute health resources; and incorporating market mechanisms into the health care environment to better respond to expectations of health care consumers. The fundamental purpose of this article is to analyze certain concepts that define and explain the origin of the 1990s health care reforms in Latin America and to refute some of the more important principles, such as: the belief that improving the functional efficiency of the health care system alone would improve the health of the population; the excessive concern with the administrative and structural aspects of health systems without a discussion of the underlying theoretical models; the idea that access, in and of itself, can guarantee "equity in health"; and lastly, the undo emphasis that was placed on individual "risk factors" as the cause of all illness.

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El denominador común en la mayoría de las reformas sanitarias llevadas a cabo desde los años noventa es la búsqueda de mecanismos para hacer frente a la escasez de recursos, el logro de una financiación equitativa y sostenible, la meta de una producción sanitaria más eficiente y la distribución de recursos de manera efectiva en los sistemas sanitarios, aspectos que constituyen nuevos desafíos de las políticas sanitarias actuales. En este artículo se analizarán los fundamentos teóricos de dichos mecanismos y los dilemas éticos que la racionalización genera en el sector de la salud, especialmente en lo relacionado con los costos compartidos, los criterios para establecer a qué y a quiénes darle prioridad, la definición del papel de los expertos y de la comunidad en este proceso de determinación de prioridades y las tensiones que se pueden presentar cuando se intenta balancear las metas de equidad, eficiencia y financiación sostenible de los servicios de salud.

The common factors in most of the health care reforms held from the nineties are the searching of mechanisms to face the scare of resources, the achievement of an equitable and sustainable financing, the goal of a more efficient sanitary production and an effective way for distribution of resources in the sanitary systems. All those factors constitute news challenges for the actualsanitary policies. Theoretical foundations of the main sanitary resources rationalization strategies and the ethical dilemmas that they cause in health sector will be analyzed here, especially the establishment of share costs, definition of what to give priority in the selection for clinical or public health interventions, the role of experts and community in the process of priority definitions and the tensions when trying to balance the targets to equity, efficiency and economical sustainabilityof the health services.

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Objetivos: analizar la concordancia entre el índice de masa corporal (IMC) y la albúmina como método diagnóstico de desnutrición en pacientes en diálisis.Diseño y métodos: estudio analítico de métodos diagnósticos.Las mediciones se realizaron por medio del análisis estadístico Stata.Pacientes: el estudio se realizó con un grupo de 76 pacientes de hemodiálisis y 15 pacientes de diálisis peritoneal durante cuatro meses en la unidad renal de Fresenius Medical Care, Armenia.Mediciones: en la consulta médica y nutricional de las unidades renales se obtiene el índice de masa corporal y la albúmina de los pacientes. Para el presente estudio en los meses de febrero a mayo del 2005 se correlacionaron estos dos parámetros en 76 pacientes de hemodiálisis para un total de 305 muestras; se hizo lo mismo con 15 pacientes de diálisis peritoneal para un total de 60 muestras. Es importante anotar que se realizaron varias mediciones en un mismo sujeto, porque son pacientes con riesgo de desnutrición por su enfermedad de base, por lo tanto, el IMC y la albúmina pueden variar de un mes a otro.Resultados: en los pacientes con hemodiálisis el análisis de las 305 muestras concluyó que en 11 existía concordancia entre el índice de masa corporal menor de 20 kg/m2 y albuminemia menor de 3.5 mg/dL; en 64 muestras se encontró albuminemia mayor de 3.5 mg/dL con IMC menor de 20 kg/m2; en 33 muestras se encontró albuminemia menor de 3.5 mg/dL con IMC mayor de 20 kg/m2; en 197 muestras se halló concordancia entre IMC mayor de 20 kg/m2 y albuminemia mayor de 3.5 mg/dL. Para un índice de Kappa de 0.004 y una correlación de Pearson de 0.023.

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El propósito de este artículo es debatir la concepción que subyace a estas propuestas en términos de la mercantilización de la atención sanitaria; analizar algunas de las dificultades de la aplicación del mercado en los sistemas de salud y reflexionar sobre las consecuencias éticas que ha tenido la "medicina gerenciada" en la práctica médica y en la relación médico-paciente.

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