Contribución al estudio de la mente del terapeuta (Deseos y Pensamientos) relacionado con la Contratransferencia en el contexto de la Supervisión / Contributions to the studies of the therapist's mind (whishesand thoughts) related to the countertransference in the contextofsupervision

El presente trabajo se centra en un estudio preliminar en aras de aplicar el Algoritmo David Liberman (ADL) como instrumento en el campo de la supervisión en un texto, tomado como informe de un supervisante, que pretende tratar el problema relacionado con el cambio psíquico desde las intervenciones del analista y desde una dificultad que surge con el uso que hace el paciente de la intervención para atacar al análisis. Comienza con un estudio de un enactment contratransferencial relatado por el analista, y luego analiza la construcción teórica presentada por él, identificando que su elaboración conceptual aún era inducida por el influjo del discurso del paciente. El énfasis de la investigación propuesta es aplicar la taxonomía de las intervenciones junto a la perspectiva de los errores del pensamiento aportadas por Maldavsky (2017). Se propone articular la práctica clínica y la elaboración conceptual, tal como ocurre en la supervisión AU

The present work presents the possibility of applying the David Liberman Algorithm (ADL) as an instrument in the field of supervision, from a text taken as a report by a supervisor, which aims to address the problem related to psychic change from the analyst's interventions and of a difficulty that arises from the patient's use of the intervention to attackthe analysis. It begins with a study of a countertransferential enactmentreported by the analyst, and later analyzes the theoretical construction presented by him, identifying that his conceptual elaboration was still induced by the influx of the patient's speech. The emphasis of the investigation lies in developing a foundation regarding the link between clinical practice and conceptual elaboration, guided by the categories related to the taxonomy of interventions and origin, function and errors of thought presented by Maldavsky, as occurs in a supervisión AU

Heterogeneity of the tumor immune microenvironment and clinical interventions / 医学前沿

The tumor immune microenvironment (TIME) is broadly composed of various immune cells, and its heterogeneity is characterized by both immune cells and stromal cells. During the course of tumor formation and progression and anti-tumor treatment, the composition of the TIME becomes heterogeneous. Such immunological heterogeneity is not only present between populations but also exists on temporal and spatial scales. Owing to the existence of TIME, clinical outcomes can differ when a similar treatment strategy is provided to patients. Therefore, a comprehensive assessment of TIME heterogeneity is essential for developing precise and effective therapies. Facilitated by advanced technologies, it is possible to understand the complexity and diversity of the TIME and its influence on therapy responses. In this review, we discuss the potential reasons for TIME heterogeneity and the current approaches used to explore it. We also summarize clinical intervention strategies based on associated mechanisms or targets to control immunological heterogeneity.

Dislexia do desenvolvimento em abordagem comparada: scoping review de pesquisas produzidas no Brasil e na Austrália / Developmental dyslexia in a comparative approach: Scoping review of research produced in Brazil and Australia

O objetivo desta scoping review é apresentar propostas de intervenção voltadas à dislexia, praticadas no Brasil e na Austrália, buscando analisar possíveis diferenças e similaridades entre os dois países. O critério para inclusão dos trabalhos foi a pesquisa ter sido realizada com seres humanos; a população ter diagnóstico de dislexia; e o estudo apresentar uma abordagem de tratamento. Os resultados revelam que nas pesquisas do Brasil predominou a abordagem pautada na remediação fonológica, e, na Austrália, houve predomínio de estudos de caso. Observou-se, no entanto, que os dois países, apoiados na hipótese cognitivista da dislexia, privilegiaram aspectos de decodificação, relativizando dimensões mais amplas da linguagem escrita. Conclui-se, portanto, que existem mais semelhanças do que diferenças relacionadas aos aspectos de tratamento clínico.

The aim of this scoping review is to present dyslexia intervention proposals, practiced in Brazil and Australia, seeking to analyze possible differences and similarities between the two countries. The criterion for including the works was the research was carried out with human beings; the population is diagnosed with dyslexia; and the study presents a treatment approach. The results show that in the Brazilian studies the phonological remediation approach predominated, and in Australia, case studies predominated. It was observed, however, that the two countries, based on the cognitivist hypothesis of dyslexia, favored aspects of decoding, relativizing broader dimensions of written language. It is concluded, therefore, that there are more similarities than differences related to aspects of clinical treatment.

O psicólogo no hospital: relato de experiência de intervenção na enfermaria pediátrica / The psychologist in the hospital: report of experience in the pediatric infirmary / El psicólogo en el hospital: experiencia de intervención en la enfermería pediátrica

objetivo deste trabalho foi relatar a experiência de estágio com técnicos de enfermagem da enfermaria pediátrica de um hospital público na região norte do Paraná. A intervenção teve como finalidade oferecer um espaço de escuta e acolhimento para questões relativas à saúde mental desses trabalhadores da saúde. Os encontros ocorreram semanalmente, utilizando o método de intervenção clínica e psicossocial. Participaram sete técnicos de enfermagem do período matutino. Por meio dos resultados foi possível identificar fatores que influenciam a saúde física e mental dos trabalhadores, podendo levar ao adoecimento, como: conflitos com a equipe, estresse, pouco reconhecimento do trabalho, morte e luto. Além deste enfoque, a intervenção possibilitou um ambiente para trocas pessoais e expressão das subjetividades e potencialidades desses trabalhadores.

The objective of this study was to report the experience of internships with nursing technicians of the pediatric ward of a public hospital in the northern region of Paraná. The purpose of the intervention was to provide a listening and reception space for questions related to the mental health of these health workers. The meetings occurred weekly, using the method of clinical and psychosocial intervention. Seven nurses from the morning period participated. Through the results, it was possible to identify factors that influence the physical and mental health of the workers, which can lead to illness, such as: conflicts with the team, stress, poor recognition of work, death and mourning. In addition to this approach, the intervention provided an environment for personal exchanges and expression of the subjectivities and potentialities of these workers.

El objetivo de este trabajo fue relatar la experiencia de práctica con técnicos de enfermería de la enfermería pediátrica de un hospital público en la región norte de Paraná. La intervención tuvo como finalidad ofrecer un espacio de escucha y acogida para cuestiones relativas a la salud mental de esos trabajadores de la salud. Los encuentros ocurrieron semanalmente, utilizando el método de intervención clínica y psicosocial. Participaron siete técnicos de enfermería del período matutino. Por medio de los resultados fue posible identificar factores que influencian la salud física y mental de los trabajadores, pudiendo llevar al enfermo, como: conflictos con el equipo, estrés, poco reconocimiento del trabajo, muerte y luto. Además de este enfoque, la intervención posibilitó un ambiente para intercambios personales y expresión de las subjetividades y potencialidades de esos trabajadores.

Second generation sequencing detection breast cancer susceptibility gene variants for risk prediction and clinical treatment / 中国肿瘤临床

Objective:To investigate the function of breast cancer susceptibility gene variants in predicting breast cancer risk and guid-ing clinical treatment through DNA sequencing. Methods:This study involved 146 patients, 71 high-risk cases, and 55 healthy people, totaling 272 cases. The subjects were treated in Tianjin Medical University Cancer Institute and Hospital from November 2013 to July 2015. Genomic DNA was sequenced by a second generation sequencing platform. All exon areas of six common breast cancer suscepti-bility genes (BRCA1, BRCA2, PTEN, STK11, TP53, and RAP1) were sequenced through amplicon sequencing method. Meaningful vari-ants including single nucleotide variants (SNVs), insertion-deletions (InDels) and nonsense mutations were selected and statistical methods, such as t test andχ2 test, were used to analyze the statistical differences in incidence rates among three groups. Results:A total of 177 meaningful variants were confirmed, including 50 SNVs, 8 nonsense mutations, and 9 InDels. Among the variants, 31 were recorded in the Exome Aggregation Consortium (ExAC), 40 were noted in ClinVar database, and 21 were not encoded in the present da-tabase, which were defined as new variants in this study. Conversely, 57 variants (85.1%) were found in breast cancer patients and high-risk cases, and the incidence of axillary lymph node metastasis (P=0.010) and pathological stages (P=0.002) in mutation positive patients were both higher than mutation negative patients. Moreover, the percentage of family history of cancer (P=0.005) and triple negative breast cancer (P=0.009) were both higher in patients carrying pathogenic mutations than in nonpathogenic patients. Conclu-sion:Breast cancer susceptibility gene variants may not only be a tool used to predict the risk of getting breast cancer but also a mean-ingful guideline for the clinical treatment and prognosis evaluation.

Community versus clinical cognitive-behavioral intervention in young-adult Spanish population with generalized social phobia / Intervención cognitivo-conductual comunitaria versus intervención clínica en jóvenes adultos españoles con fobia social generalizada

Ei objetivo del estudio es mejorar los resultados informados por las revisiones sobre el tratamiento de adultos con Fobia social generalizada. La muestra la integraron 91 participantes con Fobia social generalizada (EM: 19.90 años; DT: 1.05) asignados aleatoriamente a tres condiciones experimentales, evaluados antes y después del tratamiento, y a los 6, 12, y 24 meses en los grupos tratados. Los resultados muestran (a) la efectividad de la detección en el contexto comunitario versus la intervención clínica, en el corto y medio plazo, y (b) una mejora significativa de los efectos del tratamiento, frente a los de las revisiones de las intervenciones clínicas ad hoc, tanto en los abandonos como en las tasas de recuperación. Ello permite concluir que esta modalidad de aplicación del tratamiento cognitivo-conductual puede ser una estrategia complementaria a la convencional con la que mejorar los resultados actuales de la intervención psicológica en este trastorno.

The study investigates how to improve the results reported by the reviews on the effects of clinical interventions in adults with Generalized social phobia. The sample was composed of 91 participants (median age = 19.90 years, SD = 1.05) randomly assigned to three experimental conditions. The evaluations were conducted before and after treatment in all three groups and at 6-, 12-, and 24-month follow-up for the treatment groups. The results show (a) the effectiveness of the cognitive-behavioral strategy of detection and intervention, in a community context, versus clinical intervention both for the short and medium term; and (b) a significant improvement over the percentages of dropouts and of rates of complete recovery from the disorder. These findings allow us to conclude that the cognitive-behavioral strategy of detection and intervention, in a community context is shown to be a complementary intervention to the conventional and with high efficiency ratios.

Investigación empírica con el algoritmo David Liberman de la contratransferencia no declarada: método y aplicaciones / Empirical research on the unreported counter transference, with the David Liberman algorithm: method and applications

Objetivo: exponer un método y su ejemplificación para estudiar la perturbación contratransferencial duradera y no declarada. Operacionalización del concepto: falla clínica combinada con deseos y defensas perturbadores en el terapeuta. Instrumentos: algoritmo David Liberman. Procedimientos: 1) para la detección de las fallas clínicas en las intervenciones del terapeuta y 2) para la detección de sus deseos y defensas. Ejemplificación:10 casos. Discusión: 1) Se dan diferentes tipos de enactment contratransferenciales, en que el terapeuta se ubica en el lugar del paciente o en el de un personaje de su vida psíquica, o se defiende de ubicarse en dicha posición. 2) En estos enactments es posible investigar los deseos y las defensas del terapeuta, a lo cual se suman identificaciones con el paciente o un personaje de su mundo psíquico e inclusive introyecciones de sus estados somáticos. 3) Las fallas clínicas derivan a veces de las perturbaciones contratransferenciales del terapeuta, pero también pueden ser consecuencia de una limitación en la formación, que se combina con las perturbaciones antedichas. 4) El aporte metodológico consistió sobre todo en el desarrollo y la aplicación de los procedimientos de empleo del ADL. Los mismos procedimientos pueden aplicarse en el estudio de la contratransferencia entendida en sentido amplio.

Objective: to present a method with exemplification to study the lasting and unreported countertransferential perturbation. Operationalization of the concept: clinical inaccuracy combined with wishes and pathological defenses in the therapist. Instruments: David Liberman algorithm. Procedures: 1) for the detection of clinical inaccuracies in the therapist's interventions and 2) for the detection of his wishes and defenses. Exemplification: 10 cases. Discussion: 1) Different types of countertransferential encatments in which the therapist positions himself in the place of the patient or of a character in his psychic world, or defends himself from being in that position. 2) In these enactments it's posible to investigate the therapist's wishes and defenses to which are added identifications with the patient or with a character existing in his psychic world, and even introjections of the patient's somatic states. 3) Clinical inaccuracies are sometimes derived from the therapist's countertransferential perturbations, but may also be caused by training limitations combined with the mentioned perturbations. 4) The methodological contribution consisted mostly in the development and application of procedures for the use of the DLA. The same procedures can be applied to the study of countertransference in the broad sense of the term.

Higiene e saúde mental: o cuidado com o corpo na intervenção clínica de um CAPSI / Higiene y salud mental: el cuidado con el cuerpo en la intervención clínica de un CAPSI / Hygiene and mental health: body care in the clinical intervention in a CAPSI

Objective: report the experience of personal hygiene as an aspect of the clinical intervention in a Psychosocial Care Center for Children and Adolescents (CAPSi) in the state of Rio de Janeiro, Brazil. Method: this is a descriptive study, with an experience report design, organized into two moments: at the first, a workshop with guardians was created, consisting of psychologists, nursing teams, pharmacists, physicians, and dental team (the latter two as guests from the primary health center); at the second, problems/limitations were identified, as well as the need for creating strategies that could keep the participation of guardians in the workshops. Results: low adherence of parents was found, leading us to think of other actions more effective. Conclusion: it is hoped that this study can provide significant reflections on strategies for mental health in primary care and contribute to the practice in a CAPSi.

Objetivo: relatar a experiência da higiene pessoal como aspecto da intervenção clínica de um Centro de Atenção Psicossocial Infanto-Juvenil (CAPSi) no estado do Rio de Janeiro. Método: trata-se de um estudo descritivo, do tipo relato de experiência, organizado em dois momentos: no primeiro foi criada uma oficina com os responsáveis, composta por psicólogos, equipes de enfermagem, farmacêuticos, médicos e equipe de odontologia (os dois últimos como convidados da unidade básica de saúde); no segundo foram identificados problemas/limitações, assim como a necessidade da criação de estratégias que sustentassem a participação dos responsáveis nas oficinas. Resultados: evidenciou-se uma baixa adesão dos pais, levando-nos a pensar outras ações mais efetivas. Conclusão: espera-se que este estudo possa trazer importantes reflexões acerca de estratégias para a saúde mental na atenção básica e contribuir para a prática do CAPSi.

Objetivo: reportar la experiencia de la higiene personal como un aspecto de la intervención clínica en un Centro de Atención Psicosocial para Niños y Jóvenes (CAPSi) en el estado de Río de Janeiro, Brasil. Método: se trata de un estudio descriptivo, un reporte de experiencia, organizado en dos momentos: en el primero, se creó un taller con los cuidadores, que comprende psicólogos, equipos de enfermería, farmacéuticos, médicos y equipo dental (los dos últimos como invitados del centro de salud primaria); en el segundo, se identificaron problemas/limitaciones, así como la necesidad de la creación de estrategias que podrían mantener la participación de los cuidadores en los talleres. Resultados: se constató una baja adherencia de los padres, que nos llevó a pensar en otras acciones más eficaces. Conclusión: se espera que este estudio pueda proporcionar reflexiones importantes sobre estrategias para la salud mental en la atención primaria y contribuir a la práctica de un CAPSi.

To elaborate the pathogenesis and clinical intervention of metabolic syndrome / 中华内分泌代谢杂志

The metabolic syndrome (MS) is one of the major risk factors for cardiovascular disease.The pathogenesis of MS is not fully understood.In addition to insulin resistance and central obesity,some other factors such as resting heart rate are also thought to play certain roles.The primary strategy of the intervention is still relying on lifestyle modification including healthy dietary habits.

Analysis and Clinical Intervention of Off-label Drug Use of Thymopentin in Our Hospital / 中国药房

OBJECTIVE:To provide reference for rational drug use in the clinic. METHODS:Medical records of 300 inpa-tients receiving thymopentin were randomly sampled from our hospital during Jul. 2013-Jun. 2014. The indication,solvent dilution, route of medication,dosage,medication course and contraindications were analyzed and evaluated. Comment result fed back and ef-fective clinical invention was done. RESULTS:There was a certain degree of off-label use of thymopentin,and the off-label drug use accounted for 38.33%. Through examination and clinical intervention on clinical rational drug use, remarkable results had been achieved. Thymopentin prescription sampling were analyzed statistically in the third quarter of 2014,and the off-label drug use rate dropped to 14%. CONCLUSIONS:We should strengthen prescription comments and feedback,effective clinical invention should be done,to promote rational use of thymopentin.

Para uma clínica do uso de álcool e drogas com adolescentes das comunidades do Rio de Janeiro / For clinical use of alcohol and drugs with adolescents from the Rio de Janeiro communities

Analisando circunstâncias e elementos clínicos paradigmáticos, constata-se que as trajetórias de jovens das comunidades populares no que se refere a problemas com a Lei por uso e tráfico de drogas são, na verdade, típicas, isto é: indicam, sob eventos meramente singulares, uma produção intensa e institucionalizada desses jovens enquanto "foras da lei". Omitir esta dimensão do problema pode tornar a pesquisa científica aliada de estruturas que produzem delinquência. No entanto, uma prática derivada da clínica psicanalítica e amparada por uma reflexão sobre a institucionalidade questiona como a relação que esses adolescentes constroem com sua própria palavra nas instâncias de tratamento pode deslocar esses mecanismos institucionais.

For a clinic of drug and alcohol abuse with adolescents from popular communities in Rio de Janeiro. Parting from clinical circumstances and paradigmatic elements, the paper argues that many of the trajectories of youngsters from popular communities facing problems with the law regarding the use and trafficking of drugs are, indeed, typical. They indicate, under mere singular events, an important and institutionalized production of these young people as outlaws. Overlooking this dimension of the problem may compromise scientific research with structures that produce delinquency. Whereas a practice oriented towards psychoanalytic clinic, informed by some reflection on the institutional framework, questions how the relation these adolescents develop, to their own word, in treatment, can change these institutional mechanisms.

Estresse e zumbido: o relaxamento como uma possibilidade de intervenção / Stress and tinnitus: relaxation as a possibility of intervention / El estrés y el zumbido: el relajamiento como una posible intervención

O objetivo desta pesquisa foi verificar a presença de estresse em pessoas com queixa de zumbido e o efeito do relaxamento progressivo na percepção do zumbido e no estresse. O estresse foi avaliado em 50 pacientes, e a intervenção ocorreu com 12 participantes da amostra. Utilizaram-se a entrevista de anamnese, o inventário de sintomas de stress e o relaxamento progressivo. Os resultados demonstraram que o zumbido influencia a vida dos pacientes em aspectos físicos e emocionais. A intervenção com o relaxamento progressivo revelou respostas satisfatórias como alterações na percepção do zumbido e nos sintomas de estresse. A intervenção psicológica contribuiu para o controle dos pacientes em relação ao convívio com o zumbido, conduzindo-os ao aprendizado de estratégias de enfrentamento ao sintoma e ao estresse.

The aim of this study was verify the stress on people with tinnitus and the effect of progressive relaxation to modify the perception of tinnitus and reduce the stress. The stress was tested in 50 patients and the intervention was done with 12 people in the sample. In this interview was used the history, symptom inventory stress and progressive relaxation. The results demonstrate that the tinnitus affects the patient’s life in physical and emotional aspects. The intervention with the progressive relaxation showed satisfactory answers such as modification in the perception of tinnitus and stress symptoms. The psychological intervention contributed with how the patients will deal with tinnitus, leading them to learning strategies and coping with the stress and the symptoms.

El objetivo de esta investigación fue verificar la presencia de estrés de personas con queja de zumbido y el efecto del relajamiento progresivo con su reducción. El estrés fue evaluado en 50 pacientes y la intervención se llevó a cabo con 12 participantes en la muestra. Se utilizó la entrevista de anamnesis, el inventario de síntomas de estrés y el relajamiento progresivo. Los resultados mostraron que el zumbido afecta a las vidas de los pacientes en aspectos físicos y emocionales. La intervención con el relajamiento progresivo reveló respuestas satisfactorias como cambios en la percepción del zumbido y en los síntomas de estrés. La intervención psicológica contribuyó en el control de los pacientes en comparación con la convivencia con el zumbido, lo que lleva al aprendizaje de estrategias de enfrentamiento del síntoma y del estrés.

Clinical interventions of early swallowing syndrome on neonates / 中国综合临床

Objective To assess the efficacy of clinical intervention of early swallowing syndrome on neonates. Methods Eighty-six cases of normal newborns were enrolled in the study, including 44 cases of natural delivery,32 cases of cesarean section,8 cases of premature infant. The cases started vomitting before feeding the milk, became more severe after feeding the milk. once the pathological factors were excluded, the cases were treated with breastfeeding, warm water enema, massaging the lower abdomen, 1% sodium bicarbonate solution to the gastric lavage. Results A variety of clinical interventions on the control of neonatal swallowing syndrome results are obvious. Conclusions Early detection early intervention can prevent complications occurring.

O uso da psicoeducação no tratamento do transtorno bipolar / Use of psychoeducation in the treatment of bipolar disorder

O transtorno bipolar apresenta usualmente relevante cronicidade e severidade de sintomas, causando prejuízos psicossociais. O tratamento farmacológico é considerado indispensável para pacientes bipolares. Contudo, na esfera psicossocial, uma associação entre estressores e a precipitação de episódios bipolares tem sido claramente documentada, salientando a necessidade de intervenções nesta esfera. A psicoeducação consiste em uma modalidade de intervenção psicossocial. O presente estudo visou investigar na literatura científica os resultados obtidos através do uso da psicoeducação no tratamento do transtorno bipolar. A psicoeducação se apresenta como um modelo eficaz para adesão ao tratamento psicofarmacológico, melhor compreensão e entendimento do transtorno, redução do número de episódios maníacos, menor número de recaídas e internações, aumento do funcionamento social bem como para um melhor manejo de situações de crise e sentimentos de culpa. Da mesma forma, a psicoeducação se apresenta como uma alternativa importante para familiares de pacientes com transtorno bipolar. Conclui-se que a psicoeducação, embora não substitua o tratamento medicamentoso, tem se mostrada efetiva na otimização significativa dos efeitos dos tratamentos farmacológicos e de seus resultados além de apresentar características preventivas para recaídas e para saúde mental dos familiares.

Bipolar disorder shows significant chronicity and severity of symptoms usually causing psychosocial damage. Pharmacological treatment is considered essential for bipolar patients. However, in the psychosocial field, an association between stressors and precipitation of bipolar episodes has been clearly documented, highlighting the need for intervention in this field. As for psychoeducation, this consists of a psychosocial intervention model. The present study aimed to investigate scientific literature in respect of the outcomes of psychoeducation as a part of the treatment for bipolar disorder. Psychoeducation is seen to be a successful model in the adherence to psychopharmacological treatment, in the greater awareness and understanding of this disorder, by decreasing the number of maniac episodes as well the number of relapses and hospitalizations, improving coping and social skills. In the same way, psychoeducation offers an important alternative for the relatives of bipolar patients. It may be concluded that psychoeducation is not a substitute for pharmacological treatment, but, it has been effective in a significant optimization of the effects of pharmacological treatment.

Clínica de estomas / Stoma clinic

El objetivo de este trabajo es dar a conocer el qué y por qué de la Clínica de Estomas en el Hospital de Especialidades del Centro Médico Nacional Siglo XXI la cual, debido a la creciente demanda de pacientes sometidos a cirugía que requieren como medida paliativa o terapéutica la creación de un estoma, se creó en 1999, con la finalidad de brindar atención especializada­en coordinación con otros departamentos del hospital­, proporcionar atención eficaz, de y con calidad, unificar criterios, fomentar el autocuidado, apoyar la adaptación e integración al nuevo estilo de vida y vigilar los derechos que tiene el paciente ostomizado, medida que ha permitido en un corto plazo obtener índices de eficiencia y productividad significativos en beneficio de la salud de los pacientes y de la organización del servicio; al mismo tiempo, ha proyectado la participación de personal de enfermería calificado en la atención de estos pacientes, delimitando los diferentes roles e intervenciones en las distintas etapas del proceso de atención e impulsando actividades independientes que apoyan la rehabilitación y adaptación del paciente a su nuevo estilo de vida.

The present work describes the purpose of creating the Clinic of stomas at the Hospital de Especialidades del Centro Médico Nacional Siglo XXI, due to the increasing demand of patients submissive surgery who require like paliative or therapeutic measurement the creation of stoma. The Clinic was inaugurated the at middle of 1999, offering attention specialized in coordination with other departments, to provide effective attention with quality, a unif in criteria, to promote the selfcare, adaptation and integration to the new style of life and to watch the right that they have like patients. These measurements have allowed in a short term to obtain levels of significant efficiency and productivity with benefit to patient's health and in addition to being able to identify clearly the organization of the service and its improvement. At the same time it has projected the participation of nursing staff described in the attention of these patients, delimiting the different rolls and interventions in the stages from the attention process to rehabilitation and they have impelled independent activities that support the rehabilitation, adaptation and integration of the patient to their new style of life.