Autocuidado y bienestar en residencias de psiquiatría: encuesta de opinión a los docentes / Well-Being and self-care activities in psychiatric residency training: A survey of perceptions to facultative and program directors

Introducción: los residentes de especialidad médica están expuestos a un alto nivel de burnout lo cual impacta negativamente en el profesionalismo. Esto ha promovido que los programas de residencias instalen curricularmente actividades de bienestar y autocuidado. Este estudio busca identificar la presencia de actividades de autocuidado/bienestar en residencias de psiquiatría de Chile y conocer la opinión docente respecto del tema. Materiales y métodos: se realizó un estudio descriptivo transversal invitando vía correo electrónico a 80 docentes de 3 departamentos de psiquiatría a contestar un cuestionario sobre el tema de bienestar/autocuidado de sus residentes en sus programas de formación. Se realizó un análisis cuantitativo de los datos. Resultados: un 69,4% de los encuestados señaló que su residencia no cuenta con contenidos curriculares formales o un programa de autocuidado/bienestar para sus residentes. Las actividades existentes para las residentes relacionadas al autocuidado/bienestar y mencionadas por los docentes son: supervisión, resolución de conflictos, habilidades de comunicación y apoyo o trabajo grupal guiado. Las principales barreras son la limitación de tiempo, la falta de conocimiento y el financiamiento. Discusión: el bienestar de los residentes ha ganado relevancia en los últimos años. El Consejo de Acreditación de Educación Médica para Graduados (ACGME) lo promueve activamente. En Chile, según los programas encuestados, hay poca presencia sistemática de actividades estandarizadas o programas dirigidos al autocuidado y bienestar de este grupo. Parece necesario incluir este aspecto considerando el impacto del burnout en el personal de salud especialmente en un contexto de pandemia o crisis sanitaria.

Introduction: medical speciality residents are exposed to high burnout, which harms professionalism. This mental health situation has led to creating programs promoting well-being and self-care, which have not been installed transversally in medical education. The present study seeks to identify self-care/well-being activities in psychiatry residences in Chile and the teaching interest in implementing them. Methods: 80 professors from 3 Departments of Psychiatry were invited via email to answer a questionnaire on aspects of well-being. A quantitative analysis was performed. Results: 69.4% of those surveyed said their residence does not have formal content or a self-care/well-being program for its residents. The self-care/well-being activities most included in the residents surveyed were su-pervision, conflict resolution and communication skills, and support or guided group work. The main barriers are limited time and lack of knowledge. Discussion: The well-being of residents has gained relevance in recent years, so much so that the Accreditation Council for Graduate Medical Education (ACGME) actively promotes it. In Chile, the situation seems to be different; there is a systematic lack of standardized activities aimed at self-care and the resident's well-being. Including mental health advocating programs is an essential challenge considering the context of pandemic and the relevance of preventing burnout in health personnel.

Selección de residentes en la formación de psiquiatría: ¿qué atributos buscan los docentes de un centro formador y por qué medios? / Resident selection in psychiatry: what attributes are sought and by what means?

Introducción: la formación en Psiquiatría tiene como primer desafío elegir los candidatos ideales para desempeñarse óptimamente como residentes, alcanzando las competencias necesarias para un posterior ejercicio de la especialidad. En general, no se cuenta con instrumentos específicos de selección de residentes, utilizándose diversas estrategias de elección de candidatos a la especialidad. El objetivo del presente estudio es identificar los atributos y los medios de selección que un grupo de académicos consideran necesarios al momento de seleccionar a los candidatos a sus programas de residencia en Psiquiatría. Metodología: se realizó una investigación cualitativa de tipo encuesta de percepción utilizando el Método Delphi. La encuesta se envió, por medio de una plataforma web, a todos los académicos del Departamento de Psiquiatría de la Pontificia Universidad Católica de Chile (n=39). Resultados: los atributos mencionados fueron agrupados en 8 dominios. Las principales categorías identificadas por los encuestados fueron: profesionalismo (41%), motivación por la especialidad (33%), habilidades de comunicación (13%) y estabilidad psicológica (12%). El principal instrumento mencionado para evaluar los atributos de los postulantes fue la entrevista personal. Las publicaciones científicas, las notas de pregrado y las cartas de recomendación son mencionadas secundariamente. Conclusiones: el actuar profesional en la acción médica, medido como profesionalismo, en este estudio es atributo esencial en un postulante a un programa de residencia en Psiquiatría. Aunque las entrevistas personales han demostrado poco valor predictivo con el rendimiento del residente durante su formación, siguen siendo un instrumento muy requerido en los procesos de selección de residentes.

Introduction: Training in Psychiatry has, as its first challenge, to choose the ideal candidates to perform optimally as residents, rea-ching the necessary skills for a subsequent exercise of the specialty. There are no specific instruments for selecting residents, but many different strategies are used to select proper candidates. The primary objective of this study is to recognize the attributes academics seek in a psychiatry residency applicant. The secondary objective was to identify the selection method academics thought as optimal.Methods: A qualitative investigation of perception was conducted using the Delphi Method. The perception survey was sent through a web platform to all academics of the Department of Psychiatry of the Pontificia Universidad Católica de Chile (n = 39).Results: Attributes were grouped into eight domains. The main identified categories were: professionalism (41%), specialty interest (33%), communication skills (13%), and psychological balance (12%). A personal interview was seen as the current optimal selection method. Publications, undergraduate scores, and letters of recommendation were also taken into account.Conclusions: Professionalism, is seen as an essential attribute in an applicant for a psychiatry residency program. Although personal interviews have shown little predictive value related to the resident's performance during their training, they are still a very common and valued instrument used in the resident selection processes.

Rechazo de los padres a la vacunación obligatoria en Chile. Desafíos éticos y jurídicos / Parental refusal to mandatory vaccination in Chile. Ethical and legal challenges

Resumen: Este artículo se presenta como una reflexión ética y jurídica acerca de la tendencia actual de los pa dres a rechazar la vacunación de sus hijos en un régimen jurídico que establece la obligatoriedad de determinadas vacunas. Se analizan los principales argumentos que los padres usan para rechazar las vacunaciones obligatorias, y, en concreto: el temor a los efectos negativos que la vacunación pueda provocar en el menor; la violación del "derecho a la autonomía"; las creencias religiosas o pseudo- filosóficas; la resistencia a la intervención del Estado en asuntos personales o familiares. De esto, nace un necesario análisis ético sobre la vacunación infantil. Finalmente, se discute la responsabilidad de los padres y del Estado (autoridad sanitaria) en el cuidado de los menores de edad. La vacunación es un beneficio tanto para el inoculado como para la comunidad, la mejor política preventiva. Al mismo tiempo, se configura como un caso complejo que demanda un debate profundo, cuyo fin debe ser el tránsito desde un aparente conflicto entre los padres y el Estado, a una convergencia por el cuidado de los menores de edad. En otros términos, se recalca el hecho de que los padres, más allá del cum plimiento de un deber normativo heterogéneo, deben actuar motivados por la adhesión voluntaria al bien del hijo y de la comunidad.

Abstract: This article is an ethical and legal reflection about the current trend of parents to refuse vaccination of their children under a legal regime that establishes mandatory use of certain vaccines. We analyze the main arguments used by parents to refuse obligatory vaccination, i.e., the fear of the negative effects that vaccination may have on the child; the violation of the "right to autonomy"; religious or pseudo-philosophical beliefs; and the resistance to the State intervention in personal or family mat ters. Therefore, this statement implies a necessary ethical analysis of childhood vaccination. Finally, it will be discussed the responsibility of parents and the State -the health authority- in the care of mi nors. Vaccination is a benefit for both the inoculated and the community, the best preventive policy. At the same time, it is considered a complex case that demands a profound debate, whose purpose should be the transition from an apparent conflict between parents and the State, to convergence for the care of minors. In other words, it is emphasized the fact that parents, beyond the fulfillment of a heterogeneous normative duty, must act motivated by voluntary adherence to the best interest of the child and the community.

La ética médica en discusión: análisis de los principales temas sobre ética médica en la práctica clínica tratados en revistas nacionales de medicina y bioética 1998-2013 / Medical ethics argumentation: analysis of main topics about medical ethics in clinical practice dealt in national journals of medicine and bioethics 1998-2013 / A ética médica em discussão: análise dos principais temas de ética médica na prática clínica em revistas nacionais de medicina e bioética 1998-2013

El objetivo de esta investigación es identificar los principales temas de la discusión sobre de ética médica en la práctica clínica en Chile que se suscitan en las revistas de Medicina y Bioética chilenas. Se identificaron 143 artículos que fueron sometidos a un análisis sistemático utilizando técnicas de comparación, codificación y análisis de textos propios del enfoque de la Teoría Fundamentada. Se distinguieron 30 temas en la discusión, en la que predomina el tratamiento de la ética desde la "deontología profesional". También se observan discursos emergentes de una ética que apela a bienes y valores superiores a los deberes profesionales en la búsqueda del bien del paciente, en el marco de un proceso de transformación del contexto en que se ejerce la práctica clínica.

The aim of this investigation is to identify the main topics of the discussion about medical ethics in clinical practice in Chile. 143 articles in Chilean medical and bioethics journals were identified. They were put under a systematic study using comparison, codification and text analysis techniques of the Grounded Theory approach. 30 subjects were identified in the discussion, where the treatment of the ethics from a "professional deontology" predominates. Emergent speeches of an ethics that appeals to goods and values superiors to the professional duties in the search of the good of the patient can be found. The transformation of the context in which the clinical practice takes place is the background of the discussion.

O objetivo desta pesquisa é identificar os principais tópicos da discussão sobre ética médica na prática clínica no Chile, presentes nas revistas nacionais de medicina e bioética. Identificaram-se 143 artigos que foram submetidos a uma análise sistemática, utilizando-se técnicas de comparação, codificação e análise de textos próprios da abordagem da Teoria Fundamentada. Identificaram-se 30 temas na discussão, nos quais predominam o tratamento da ética a partir da "deontologia profissional". Também se observam discursos emergentes de uma ética que apela aos bens e valores superiores aos deveres profissionais na busca pelo bem do paciente, no âmbito de um processo de transformação do contexto em que é exercida a prática clínica.

El proceso de transición de servicios pediátricos a adultos: visión de adolescentes hospitalizados portadores de enfermedades crónicas / The transition process from paediatric to adult services: a perspective from hospitalised adolescent sufferers of chronic diseases

INTRODUCCIÓN Las enfermedades crónicas durante la adolescencia son un gran desafío para el paciente, su familia y los proveedores de salud. La transición desde los servicios de salud pediátricos a adultos involucra el proceso de traspaso programado y planificado, de adolescentes portadores de enfermedades crónicas, para mantener una buena calidad de vida y desarrollo biopsicosocial. No existe, actualmente, un modelo único de transición. El objetivo del estudio es comprender el proceso de transición desde la perspectiva de adolescentes hospitalizados, para colaborar al diseño de un modelo acorde a las necesidades estudiadas. PACIENTES Y MÉTODO Incluye entrevistas semiestructuradas a 13 adolescentes portadores de enfermedades crónicas, hospitalizados en 2 centros asistenciales de Santiago de Chile, en un estudio analítico-relacional, sostenido por una metodología de carácter cualitativo. RESULTADOS En el análisis destacan 5 temas principales: experiencia de la vivencia de la enfermedad, importancia de la relación médico-paciente, concepto de autonomía limitado a lo farmacológico, ausencia de un proceso de transición propiamente dicho y la identificación de barreras y necesidades para una transición adecuada. CONCLUSIONES Este estudio es pionero en Chile en explorar el fenómeno de la transición en adolescentes con enfermedades crónicas. Enfatiza la necesidad de reforzar el concepto de autocuidado y autonomía desde etapas tempranas del cuidado y la importancia de la planificación temprana de un proceso de transición saludable, de acuerdo a las necesidades detectadas por los propios adolescentes.

INTRODUCTION Chronic illnesses during adolescence are a big challenge for the patient, his or her family, and health care providers. The transition from paediatric health services to adult health services involves a programmed and planned transfer process of adolescent sufferers of chronic illnesses, in order to maintain a high quality of life and bio-psycho-social development. There is currently no transition model. The objective of the study is to understand the transition process from the perspective of hospitalised adolescents to collaborate towards the design of a model that meets the needs studied. PATIENTS AND METHOD Semi-structured interviews with 13 adolescent sufferers of chronic illnesses, hospitalised in two healthcare centres in Santiago, Chile, in one analytical-relational study, supported by qualitative methodology. RESULTS In the analysis, 5 major themes stand out: experience of living with the illness, the importance of the doctor-patient relationship, the concept of limited autonomy to the pharmacology, the absence of the transition process as such, and the identification of barriers and needs for an adequate transition. CONCLUSIONS This study is new in Chile in that it explores the phenomenom of the transition of adolescents with chronic illnesses. It emphasises the need to reinforce the concept of self-care and autonomy from early stages of care, and the importance of early planning of a healthy transition process, in accordance to the detected needs of the adolescents themselves.

Ética de la investigación en salud pública / Ethics of the investigation in public health

Los aspectos éticos de la salud pública y de la epidemiología han surgido como un campo nuevo en la bioética. El trabajo comenta la discusión actual sobre los problemas derivados de las actitudes éticas de los investigadores en este campo y aquellos aspectos éticos relevantes por considerar en el diseño y ejecución de investigaciones en salud pública. Se propone como fundamento de la acción ética promover el ejercicio práctico de las virtudes del investigador. Además, se recomienda como guía de práctica, resguardar al menos siete aspectos éticos en las investigaciones en salud pública.

Aproximación al estado de salud mental del profesorado en 12 escuelas de Puente Alto, Santiago Chile / Mental health of teachers from 12 basic schools in a suburban community in Chile

Mental health of teachers is a primary concern, considering the important deficiencies in the Chilean educational system. Aim: To explore mental health in teachers from local primary schools. Material and methods: The 12 question version of the Goldberg health questionnaire (a self administered instrument) was applied to 139 teachers working in basic schools in a suburban community. Results: One hundred twenty teachers (99 females) answered the questionnaire. A possible emotional problem was detected in 28.6 percent. The life prevalence of mental health problems was 32 percent. Relationships with children were the best perceived and relationships with superiors were the worst perceived. A higher social valuation of teachers and better salaries were the two variables associated with a better satisfaction with work. The number of working hours were directly related to mental health problems. Multivariate analysis showed that age was independent and negatively correlated with Goldberg score and that general satisfaction with work was directly related to the quality of relationships with superiors. Conclusions: Age and number of working hours were two risk factors for mental problems identified in this sample. A better social valuation of teachers work, better salaries and a good relationship with children and superiors should improve labor satisfaction

Características de niños y adolescentes atendidos en un consultorio psiquiátrico del sistema privado de salud en Chile / Characteristics of children and adolescents attended in a private psychiatric outpatient clinic in Chile

Background: There is a 7 percent up to 32 percent prevalence of psychiatric problems in the pediatric population. Aim: To study the epidemiological features of children and adolescents attended in a psychiatric outpatient clinic. Material and methods: All admissions to a psychiatric outpatient clinic, of people aged 18 years old or less, during 1998, were reviewed. The causes of consultation and the diagnoses were classified according to diagnostic manuals (ICPC-WONCA and DSM-IV respectively), by three experienced psychiatrists. Results: The files of 376 patients were reviewed (200 males, mean age of females 12 years old, mean age of males 10.5 years old). Seventy three percent consulted spontaneously. The main causes of consultation were anxiety disorders and adolescence problems (28 percent). The main diagnoses were attention deficit disorder and disruptive behavior, adaptative problems, mood and anxiety disorders. There were gender differences in the diagnoses. Women attended a mean of 6.3 sessions and men attended a mean of 4 sessions. Fifty nine percent abandoned treatment. Conclusions: There is a limited access to mental health care. The low compliance with treatments must be studied and improved

Asignación de recursos en salud en Chile: consideraciones éticas en la toma de decisión / Ethical considerations about decision making in health care source allocation in Chile

Background: The inclusion of ethical aspects in the world health care reform is currently being discussed. Aim: To analyze the ethical component of health care decision making in Chile. Material and methods: A qualitative analysis of interviews with 4 health service directors, 4 public hospital directors and 1 sub director. Inquiries to 16 public hospital ethics committees, about importance of ethical components in decision making, role of ethics committees in financial issues and the feasibility of incorporation explicit ethical considerations in decision making. Results: There is an absence of explicit ethical criteria in decision making. There is little participation of directors in these issues and lack of information. Although ethical aspects are considered relevant, they are not taken into account. Ethics committees are mostly dedicated to evaluate research protocols. The community is not mentioned as a relevant actor in decision making about resource allocation. Conclusions: Health service directors and all health care personnel should be trained in bioethics. These aspects should be incorporated to their daily work

Drogadicción embriofetal por abuso de pasta base de cocaína durante el embarazo / Fetal drug addiction as a consequence of maternal cocaine base paste abuse during pregnancy

Background: Fetal drug addiction is a serious public health problem. In the United States 10 to 15 percent of children have been exposed "in utero" to cocaine. In a Chilean public health service, more than 200 offspring of cocaine free base abuser have been detected. Aim: To analyze the clinical and social features of 100 children exposed to cocaine free base during fetal development. Patients and methods: Clinical features of children born from cocaine free base consume mothers were described at birth. During subsequent follow up, growth and development, disease episodes, developmental alterations and social situation were recorded. Data was compared with other newborns from the same health service. Results: Compared to their normal counterparts, exposed children has a lower birth weight, the frequency of premature babies was thrice higher, and small-for-gestational age children were four times more common. There was also a higher prevalence of cardiac malformations, seizures and apnea. Hospital admissions were more frequent, prolonged and required more complex facilities. During follow up, undernutrition and stunting were more prevalent. Psychomotor retardation was present in 67 percent of children and behavioral disturbances in 93 percent. Most of these children are governmental protection. Conclusions: Strategies to prevent drug abuse during pregnancy and its devastating medical and social consequences should be urgently developed

Paquete básico de prestaciones basados en evidencia para el nivel primario de atención: una propuesta / Service basic package based on evidences for primary health care

Background: Health care research has demonstrated that the primary care level can provide effective services. Aim: To propose a basic package of services for primary health care in medium income countries, based on evidences about its effectiveness. Materials and methods: Scientific evidence for the effectiveness of primary care services was first sought through a systematicliterature research. Interventions with evidences of effectiveness and appropriate for the Chilean epidemiological profile were selected. The cost in US dollars for a 100.000 inhabitant population was established. Results: Fourteen programs with evidence of effectiveness were selected: immunizations, infant growth and development surveillance, pregnancy surveillance, family planning, cervical cancer screening, diabetes, hypertension, prevention of stroke, smoking cessation, treatment of problem drinkers, depression, lower respiratory infections in children of less than 6 years old, tuberculosis and palliative care. The total cost was calculated in US$ 36 per person/year. Conclusions: This proposal must be flexible, according to local conditions and changes in evidence. It is based in the "new universality" proposed by WHO, that combines a high coverage in key zones with economical realism

Mortalidad por anomalías congénitas en Chile: 1969-1997 / Mortality due to congenital malformations in Chile: 1969-1997

Background: Congenital malformations are defined as those structural, metabolic or functional defects found at birth. Aim: To study the mortality due to congenital malformations in Chile between 1969 and 1997, their type, individual, temporal and geographic variations. Material and Methods: A descriptive analisis of deaths registered by the National Statistics Institute and the Ministry of Health. Means, frequencies, raw and adjusted rates were calculated and inferences for some variables were carried out. Results: Between 1969 and 1997 ther was tendency towards a reduction in rates of mortality due to congenital malformations and an increment in their relative importance. During the period, the risk for chromosome (98 percent) and osteomuscular (67 percent) malformations increased. Men and children of less than one year had the higher risk. In 1995, 1167 deaths due to congenital malformations were registered, 90 percent in children of less than 5 years. Higher risks occurred in urban zones (with a rate of 8.25 per 100.000) in the third region (rate 11.59) and second region (rate 11.2). Most deaths occurred in hospitals (85 percent). Main causes of death were circulatory system, central nervous system and chromosome malformations. Conclusions: The differences in regional deaths due to congenital malformations suggests specific risks that deserve further study

Infección por dypilidium caninum en un lactante / A case of infection by dypilidium caninum in an infant

Dypilidium caninum es un cestode común en perros y gatos distribuido en todo el mundo. El ser humano, huesped accidental, adquiere la infección a través de las pulgas en asociación con las mascotas infectadas, siendo esta enfermedad más frecuente en niños. Presentamos el caso de una niña de un año y medio de edad, que durante siete meses eliminó proglótidas en las deposiciones, consultando en numerosas oportunidades siendo tratada con fármacos dirigidos a protozoos y nematelmintos. Finalmente, luego de la identificación del Dypilidium caninum se trató a la paciente con niclosamida, evolucionando satisfactoriamente

Estado nutricional de niños asistentes a supervisión de salud en un centro privado chileno / Nutritional status of children attending at a private health care center in Chile

Objetivo: establecer el estado nutricional de niños consultantes a supervisión de salud en un centro de salud privado chileno. Método: estudio descriptivo de consultas de control sano de niños entre 7 días y 15 años, realizadas entre 1995-1997. Se evaluó peso y talla para la edad e índice peso/talla, de acuerdo a curvas de NCHS, y el diagnóstico nutricional integrado. Se realizaron distribuciones de frecuencias y diferencias de proporciones. Resultados: se estudiaron 11.228 consultas; el 52 por ciento son varones, el promedio de edad fue de 29 meses, 8,3 por ciento eran obesos, 18,1 por ciento sobrepeso y desnutridos 4,4 por ciento. El diagnóstico de obesidad se duplicó sobre los seis años, especialmente en mujeres (vp = 0,002), y de desnutrición sobre los 10 años en varones (vp = 0,000). el perfil en menores de seis años difirió del nacional, salvo en la prevalencia de obesidad, que fue similar. No hubo diferencias entre el estado nutricional y el tipo de alimentación

Uso de andador en lactantes / Infant walkers

Objetivo: describir los riesgos de accidentes y traumatismos relacionados con el empleo de andadores en la infancia. Pacientes y Métodos: estudio retrospectivo descriptivo realizado en una muestra alectoria de 250 lactantes (6 a 1 8 meses), cuyos padres o responsables fueron encuestados en la Unidad de Pediatría Ambulatoria de la Pontificia Universidad Católica de Chile, sobre la frecuencia con que se empleo andadores, motivaciones para ello, incidencia y mecanismo de producción de accidentes, tipos de lesiones producidas. Resultados: El andador había sido usado en 169 niños (67,6 por ciento), de los cuales 77 (45,6 por ciento) sufrieron accidentes que resultaron en 1,5 lesiones por niño, 10 por ciento de ellos graves. Las razones para usar el andador fueron evitar el aburrimiento, necesidades de la madre y aprender a caminar. Las decisiones para no usarlo se originaron en temor a sus riesgos o consejo del médico. Conclusiones: El uso de andador debe hacerse con gran cautela y estrictas precauciones, pues implica considerable riesgo de accidentes y lesiones y no es recomendable si existen otras opciones más seguras para entretener y estimular al niño

Mortalidad por accidentes de tránsito en Chile, 1994: una aproximación epidemiológica / Mortality due to traffic accidents in Chile during 1994: an epidemiological approach

Traffic accidents are one of the most important public health problems in the world and produce social, work and human resources losses. Data were obtained from death certificates in which the cause of death was a traffic acciden. All death certificates obtained by the National Institute of Statistics during 1994 were used. Social, demographic and seasonal variable were recorded. During 1994 there were 1679 deaths due to traffic accidents (81 percent male), with a rate of 19.6 per 100,000 inhabitants. Gender specific risks were 19.62 and 4.48 for men and women, respectively. Mean age at the moment of death was 39 years old. Fifty three percent of deceased people were single, 42 percent married and 5 percent widowers. Ten percent had not formal education, 48 percent had basic education, 23 percent college education and 6.5 percent university education. Seventy seven percent of fatalities ocurred in urban areas. The risk of death of traffic accidents was 7.02 per 100,000 inhabitants in the metropolitan region. The information obtained in the present study may help to generate preventive strategies to control deaths caused by traffic accidents

Infección por estreptococo grupo A invasor: caracterización bacteriológica / Beta-haemolytic group A streptococci invasive infections: a bacteriological characterization

Un cambio en la expresión clínica de las infecciones producidas por el estreptococo Grupo A ha sido observado en Chile y el mundo. Una de las hipótesis que explica el cambio esta la que involucra el EBH-A como elemento que ha producido el desequilibrio en la triada ecológica. El objetivo de este trabajo es caracterizar bacteriológicamente los casos graves de infecciones por EBH-A. Se analizaron 36 cepas de 29 pacientes. Predominaron las cepas T1M1 (38 por ciento). En seis de estas cepas estudiadas hasta la fecha se detectó la presencia del gen para la toxina B y el de la toxina A en 2. Esto tiene implicaciones terapéuticas y profilácticas