Characterization of grazing behaviour microstructure using point-of-view cameras.

Grazing patterns, intake structure, and diet selection are dynamic responses to animals' feeding environment. This study uses video sequences from animal-borne cameras to capture time- and scale-dependent grazing behaviour variables related to sward explanatory conditions. We observed grazing 'through' the sheep's eyes using point-of-view (POV) cameras coupled with event logging software. Time-specific sward features were measured by sampling 'really' grazed patches identified by applying a global navigation satellite system (GNSS) precision-grazing approach. Sward variables on a Mediterranean native sward were measured for two years during the active spring plant-growth cycle. Overall, the results demonstrate that POV cameras were able to capture grazing behaviour fine-tuning to changes in sward characteristics. Sheep compensate for the decrease in sward quantity and nutritive value by increasing the size and duration at each behavioural scale (i.e., meal, bout, and station) while increasing the bout rate and decreasing the station rate. Diet composition also changed as sward matured. The proportion of forbs in the diet remained high in early and late spring, and forbs and legumes were preferred to grasses in early spring. Grazing selectivity was more pronounced in late spring, with sheep favouring the middle stratum of the sward's vertical structure, preferring green vegetative material, while enlarging the feeding niches' span and spending more time at each niche, consequently reducing the station rate. Although data collected by individual animal-borne POV cameras were representative of the flock behaviour, they may underestimate the total grazing time outside major meals. The results indicate that the use of animal-borne video cameras is suitable for assessing variations in sheep grazing behaviour patterns in complex swards.

Intelligent MONitoring System for antiviral pharmacotherapy in patients with chronic hepatitis C (SiMON-VC) / Sistema inteligente de MONitorización de la farmacoterapia antiviral en pacientes con hepatitis C crónica (SiMON-VC)

Two out of six strategic axes of pharmaceutical care in our hospital are quality and safety of care, and the incorporation of information technologies. Based on this, an information system was developed in the outpatient setting for pharmaceutical care of patients with chronic hepatitis C, SiMON-VC, which would improve the quality and safety of their pharmacotherapy. The objective of this paper is to describe requirements, structure and features of SiMON-VC. Requirements demanded were that the information system would enter automatically all critical data from electronic clinical records at each of the visits to the Outpatient Pharmacy Unit, allowing the generation of events and alerts, documenting the pharmaceutical care provided, and allowing the use of data for research purposes. In order to meet these requirements, 5 sections were structured for each patient in SiMON-VC: Main Record, Events, Notes, Monitoring Graphs and Tables, and Follow-up. Each section presents a number of tabs with those coded data needed to monitor patients in the outpatient unit. The system automatically generates alerts for assisted prescription validation, efficacy and safety of using antivirals for the treatment of this disease. It features a completely versatile Indicator Control Panel, where temporary monitoring standards and alerts can be set. It allows the generation of reports, and their export to the electronic clinical record. It also allows data to be exported to the usual operating systems, through Big Data and Business Intelligence. Summing up, we can state that SiMON-VC improves the quality of pharmaceutical care provided in the outpatient pharmacy unit to patients with chronic hepatitis C, increasing the safety of antiviral therapy (AU)

Dos ejes estratégicos de la atención farmacéutica en nuestro hospital son la calidad y seguridad asistencial y la incorporación de tecnologías de la información. En base a ellos, en el ámbito de pacientes externos, se desarrolló un sistema de información para la atención farmacéutica de pacientes con hepatitis C cró- nica, SiMON-VC, que mejorase la calidad y seguridad de su farmacoterapia. El objetivo de este trabajo es describir requisitos, estructura y prestaciones de SiMON-VC. Los requisitos exigidos fueron que el sistema de información incorpore automáticamente datos críticos desde la historia clínica electrónica en cada una de las visitas a consulta externa de Farmacia, que permita la generación de eventos y alertas, que documente la atención farmacéutica proporcionada y que posibilite la explotación de los datos con fines de investigación. Para cumplir estos requisitos SiMON-VC se estructuraron 5 apartados para cada paciente: Registro Principal, Eventos, Notas, Gráfica y Tablas de Seguimiento y Seguimientos. Cada apartado dispone de una serie de pestañas con datos codificados necesarios para el seguimiento del paciente en consulta externa. El sistema genera automáticamente alertas de efectividad y seguridad de la utilización de antivirales para el tratamiento de esta patología y como sistema de ayuda a la validación farmacéutica de la prescripción médica. Incorpora un Cuadro de Mando de Indicadores totalmente versátil, para el que se pueden definir estándares y alertas de seguimiento temporales. Permite la generación de informes y su exportación hacia la historia clínica electrónica. Posibilita la exportación de los datos a los sistemas de explotación habituales, con fines de investigación a través de Big-Data y Business Intelligence. Como conclusión se puede indicar que SiMON-VC mejora la calidad de la atención farmacéutica proporcionada en consulta externa de Farmacia a pacientes con hepatitis C crónica, incrementando la seguridad del tratamiento antiviral (AU)

Intelligent MONitoring System for antiviral pharmacotherapy in patients with chronic hepatitis C (SiMON-VC).

Two out of six strategic axes of pharmaceutical care in our hospital are quality and safety of care, and the incorporation of information technologies. Based on this, an information system was developed in the outpatient setting for pharmaceutical care of patients with chronic hepatitis C, SiMON-VC, which would improve the quality and safety of their pharmacotherapy. The objective of this paper is to describe requirements, structure and features of Si- MON-VC. Requirements demanded were that the information system would enter automatically all critical data from electronic clinical records at each of the visits to the Outpatient Pharmacy Unit, allowing the generation of events and alerts, documenting the pharmaceutical care provided, and allowing the use of data for research purposes. In order to meet these requirements, 5 sections were structured for each patient in SiMON-VC: Main Record, Events, Notes, Monitoring Graphs and Tables, and Follow-up. Each section presents a number of tabs with those coded data needed to monitor patients in the outpatient unit. The system automatically generates alerts for assisted prescription validation, efficacy and safety of using antivirals for the treatment of this disease. It features a completely versatile Indicator Control Panel, where temporary monitoring standards and alerts can be set. It allows the generation of reports, and their export to the electronic clinical record. It also allows data to be exported to the usual operating systems, through Big Data and Business Intelligence. Summing up, we can state that SiMON-VC improves the quality of pharmaceutical care provided in the outpatient pharmacy unit to patients with chronic hepatitis C, increasing the safety of antiviral therapy.

Dos ejes estratégicos de la atención farmacéutica en nuestro hospital son la calidad y seguridad asistencial y la incorporación de tecnologías de la información. En base a ellos, en el ámbito de pacientes externos, se desarrolló un sistema de información para la atención farmacéutica de pacientes con hepatitis C crónica, SiMON-VC, que mejorase la calidad y seguridad de su farmacoterapia. El objetivo de este trabajo es describir requisitos, estructura y prestaciones de SiMON-VC. Los requisitos exigidos fueron que el sistema de información incorpore automáticamente datos críticos desde la historia clínica electrónica en cada una de las visitas a consulta externa de Farmacia, que permita la generación de eventos y alertas, que documente la atención farmacéutica proporcionada y que posibilite la explotación de los datos con fines de investigación. Para cumplir estos requisitos SiMON-VC se estructuraron 5 apartados para cada paciente: Registro Principal, Eventos, Notas, Gráfica y Tablas de Seguimiento y Seguimientos. Cada apartado dispone de una serie de pestañas con datos codificados necesarios para el seguimiento del paciente en consulta externa. El sistema genera automáticamente alertas de efectividad y seguridad de la utilización de antivirales para el tratamiento de esta patología y como sistema de ayuda a la validación farmacéutica de la prescripción médica. Incorpora un Cuadro de Mando de Indicadores totalmente versátil, para el que se pueden definir estándares y alertas de seguimiento temporales. Permite la generación de informes y su exportación hacia la historia clínica electrónica. Posibilita la exportación de los datos a los sistemas de explotación habituales, con fines de investigación a través de Big-Data y Business Intelligence. Como conclusión se puede indicar que SiMON-VC mejora la calidad de la atención farmacéutica proporcionada en consulta externa de Farmacia a pacientes con hepatitis C crónica, incrementando la seguridad del tratamiento antiviral.

Detection of periodontal bacteria in atheromatous plaque by nested polymerase chain reaction.

BACKGROUND: In recent years, increasing evidence regarding the potential association between periodontal diseases and cardiovascular diseases has been identified. The available evidence underlines the importance of detecting periodontal pathogens on atheromatous plaque as the first step in demonstrating the causal relationship between the two conditions. The main aim of this investigation is to detect periodontitis-associated bacteria from carotid artery atheromatous plaque from patients who received an endarterectomy using strict sample procurement and laboratory procedures. METHODS: Atheromatous plaque from endarterectomies from carotid arteries were scraped and homogenized, and bacterial DNA was extracted. To obtain a representative concentration of amplicons, two amplifications of the bacterial 16S ribosomal-RNA gene were carried out for each sample with universal eubacteria primers by a polymerase chain reaction (PCR). A nested PCR with specific primers for the target bacteria was performed next. Statistical tests included the χ(2) test. RESULTS: Forty-two atheromatous plaque were analyzed. All of them were positive for ≥1 target bacterial species. The bacterial species most commonly found was Porphyromonas gingivalis (78.57%; 33 of 42), followed by Aggregatibacter actinomycetemcomitans (previously Actinobacillus actinomycetemcomitans) (66.67%; 28 of 42), Tannerella forsythia (previously T. forsythensis) (61.90%; 26 of 42), Eikenella corrodens (54.76%; 23 of 42), Fusobacterium nucleatum (50.00%; 21 of 42), and Campylobacter rectus (9.52%; four of 42). The simultaneous presence of various bacterial species within the same specimen was a common observation. CONCLUSION: Within the limitations of this study, the presence of DNA from periodontitis-associated bacteria in carotid artery atheromatous plaque retrieved by endarterectomy is confirmed.

Rotura prematura de membranas en gestantes a término: factores asociados al parto abdominal / Premature rupture of membranes at term: factors associated to abdominal delivery

Objetivo: Determinar factores asociados a la vía del parto en pacientes gestantes a término con rotura prematura de membranas (RPM) Diseño: Estudio descriptivo retrospectivo, tipo casos y controles. Institución: Hospital Nacional Cayetano Heredia, Lima, Perú. Participantes: Gestantes a término con RPM. Intervenciones: Estudio realizado en 140 gestantes a término con RPM que ingresaron al centro obstétrico para inducción del trabajo de parto, correspondiendo 70 casos y 70 controles, en un período de 5 años. Los datos fueron obtenidos de las historias clínicas. Principales medidas de resultados: Factores asociados al parto abdominal. Resultados: El análisis univariado determinó como factores asociados al parto abdominal al estado del cérvix (puntaje Bishop) al inicio de la inducción y la preeclampsia. Se estimó un modelo predictivo final en el análisis multivariado, hallándose como factores de riesgo la edad materna, el Bishop de ingreso menor de 4 y presencia de preeclampsia, y como factor de protección la multiparidad de la paciente. Conclusiones: Los factores de riesgo para un parto abdominal en pacientes con RPM fueron el Bishop de ingreso menor de 4, la presencia de preeclampsia y la edad materna, mientras se encontró que la multiparidad fue factor protector.

To determine factors associated with abdominal delivery in pregnant women at term with prelabor rupture of membranes (PROM). Design: Descriptive retrospective case-controlstudy. Setting: Hospital Nacional Cayetano Heredia, Lima, Peru. Participants: Pregnant women at term with PROM. Interventions: Study done in 140 women with prelabour rupture of membranes at 37 or more weeks’ gestation with no specific maternal or fetal contraindications to labor induction; 70 were control and 70 cases. Data were obtained from medical records. Main outcome measures: Factors associated to abdominal delivery. Results: Univariate analysis found uterine cervix status and preeclampsia as significant cesarean section risk factors. The final multivariable model analysis found maternal age, Bishop score less than 4, and preeclampsia as risk factors. The number of previous births was found as a protective factor. Conclusions: Cervical status (Bishop score less than 4), preeclampsia and maternal age were cesarean section risk factors in prelabor rupture of membranes. Multiparity was a protective factor.

The choice of therapy in acromegaly: results of treatment at a tertiary care hospital.

OBJECTIVE: The aim of our study was to investigate the characteristics of acromegalic patients diagnosed at a tertiary University Hospital and to evaluate the results of the recommended treatment protocols. PATIENTS AND METHODS: All our acromegalic patients were included (n=48; 27 women). Demographic, hormonal, visual and imaging data at diagnosis and during follow-up were recorded, as well as the treatments applied. RESULTS: In 73.0% of the patients, acromegaly was due to a pituitary macroadenoma. From those under periodic surveillance, 68.2% underwent surgery and 36.4% had radiotherapy. At the time of the study 88.6% of the patients were receiving medical therapy, 28.2% of them as first-line treatment. Applying current criteria, only one patient was cured by surgery. Considering normal age and sex-matched concentrations of IGF-I as a control criteria, surgery resulted in disease control in 10% of the patients who had surgery, while medical treatment controlled the disease in 76.9% (P <0.05). Of those who receive medical therapy as first-line treatment, tumour size decreased in 45.5%, while in the rest no significant changes were observed during follow-up. CONCLUSIONS: Not all centres obtain the results reported in the literature in terms of disease control and morbidity after surgical treatment of growth hormone-secreting tumours. It is possible that in some hospitals first-line medical treatment should be chosen, unless the patient has visual disturbances, as long as it is not clear that partial surgical removal of the tumour significantly improves response to medical therapy or reduces its costs.

[Interposition arthroplasty as treatment of osteochondritis of the second metatarsal head. A case report]. / Plastía de interposición en el tratamiento de osteocondritis del segundo metatarsiano. Presentación de un caso.

INTRODUCTION: Freiberg described this pathology in 1914, it is a relatively rare condition, it mainly affects the head of the second metatarsal. Treatment includes reduction of daily activity and use of orthoses. For surgical treatment numerous techniques exist such as: debridement, osteotomies, resection of the metatarsal head or the base of the phalanx, arthroscopic treatment, and arthroplasty. OBJECTIVE: To present the case of a 31 year old female, Stage V according to the Smillie classification and to describe the surgical technique of the interposition arthroplasty that was made. SURGICAL TECHNIQUE: Longitudinal incision of 2.5 cm in dorsal surface of metatarsophalangeal joint, identification of extensor tendon. Capsular incision, debridement and excision of osteophytes and regularization of the metatarsal head. The sinovial capsule is dissected and covered with the metatarsal head, finally sutured to the capsule in the plantar region. RESULTS: The patient has 2 years from surgery and is asymptomatic with 350 of flexion and 500 of extension. On simple X-rays an adequate metatarsophalangeal space can be observed. We consider that the procedure is one more alternative for the treatment of this condition.

Tripeptidyl peptidase II is dispensable for the generation of both proteasome-dependent and proteasome-independent ligands of HLA-B27 and other class I molecules.

A significant fraction of the HLA-B27-bound peptide repertoire is resistant to proteasome inhibitors. The possible implication of tripeptidyl peptidase II (TPPII) in generating this subset was analyzed by quantifying the surface re-expression of HLA-B*2705 after acid stripping in the presence of two TPPII inhibitors, butabindide and Ala-Ala-Phe-chloromethylketone. Neither decreased HLA-B27 re-expression under conditions in which TPPII activity was largely inhibited. This was in contrast to a significant effect of the proteasome inhibitor epoxomicin. The failure of TPPII inhibition to decrease surface re-expression was not limited to HLA-B27, since it was also observed in several HLA-B27-negative cell lines, including Mel JuSo. Actually, HLA class I re-expression in Mel JuSo cells increased as a function of butabindide concentration, which is consistent with an involvement of TPPII in destroying HLA class I ligands. Inhibition of TPPII with small interfering RNA also failed to decrease the surface expression of HLA class I molecules on 143B cells. Our results indicate that TPPII is dispensable for the generation of proteasome-dependent HLA class I ligands and, without excluding its role in producing some individual epitopes, this enzyme is not involved to any quantitatively significant extent, in generating the proteasome-independent HLA-B27-bound peptide repertoire.

Destinos / Destinies

Duas personagens de um filme de Érick Zonca – La vie rêvée des anges (1998) – foram objeto de escuta clínica. Assumindo integralmente a dimensão artística e literária da escuta analítica e da interpretação, os autores participam da obra de arte em exame: entram nos campos subjetivos aí operantes; reconstituem os estilos e padrões subjacentes de pensar, sentir, desejar e sofrer das duas personagens (suas metapsicologias); e oferecem sua capacidade de simbolização e verbalização às experiências de mundo de cada uma. O resultado é uma apresentação dramática do "material". A relação entre o plano fenomenológico e o metapsicológico das análises fica assim muito mais evidente do que seria possível em uma apresentação clínica convencional.(AU)

Two characters of a Erick Zonca's film (1998) La vie rêvée desanges became the object of clinical listening. Assuming entirely the artistic and literary dimension of the analytical listening and interpretation, the authors took part in the work of art under examination: they enter the subjective fields in operation; they reconstitute the styles and underlying patterns of thinking, feeling, desiring and suffering of the two characters (their metapsychologies); and offer their capacity of symbolization and verbalization to the experiences of each one's world. The end result is a dramatic presentation of the "material': The relation between the phenomenological plan and the metapsychological plan of the analyses becomes thus much more evident than it would be possible in a conventional clinical presentation.(AU)

[Distal tibial reconstruction and ankle arthrodesis in osteosarcoma (salvage technique). A case presentation]. / Reconstrucción de tibia distal y artrodesis de tobillo en osteosarcoma (cirugía de salvamento). Presentación de un caso.

UNLABELLED: Treatment of bone sarcomas is aimed in healing and secondarily rescuing the limb. With the use of chemotherapy, radiation therapy, new prostheses and availability of graft, now most tumors can be resected, reducing functional deficit. OBJECTIVE: To present a surgical option in management of osteosarcoma of distal tibia. CASE REPORT: Fifteen year-old man, starting in April 2003 with a mass in the left ankle area. June 2003 pulsatile progressive pain started, increased with activity, decreased with rest. November 2003 the physical exam: limping by left lower limb, with a tumor in the posteromedial ankle surface (3 x 2 cm), hard, not movable, regular edges, painful on palpation, Radiographic observations (November 2003), showed blastic oval stone image (4 x 3.5 cm) with expanded posterior and medial cortices with periosteal reaction. The initial biopsy report (chondroblastoma) was not consistent with the diagnostical assumption. So resection was performed 10 cm wide, placing a methylmethacrylate spacer. The final histological report was positive to osteogenic sarcoma. The patient received 11 sessions of chemotherapy. The reconstruction of the distal tibia and arthrodesis with autologous graft from the fibula, heterologous graft and stabilization with transcalcaneal nail, was done in March 2005. RESULTS: Successful evolution without tumor activity with graft integration to arthrodesis and plantigrade gait.

[Treatment of tibial non-union with a large bone defect with half-tubular fibular graft, centromedullary nailing and bone graft]. / Tratamiento de la no unión tibial con gran defecto oseo con peroné en media caña, clavo centromedular e injerto oseo.

INTRODUCTION: Non-union is most frequent in the tibia. It may occur with bone loss and is most often seen in the mid-third, mainly as a result of high-energy trauma. Our purpose is to present a treatment alternative. MATERIAL AND METHODS: Prospective, longitudinal, experimental trial conducted between 1999 and 2004. Five patients classified according to Judet and Paley were included. A half-tubular fibular graft plus an autologous and/or heterologous iliac crest graft were used with a UTN nail for stabilization purposes; mean follow-up was 24 months. RESULTS: All patients were male. High energy trauma was the cause in 100%; 5 were Gustilo III fractures; Paley B1 type was present in 60%; the mean bone defect was 7.8 cm. Grade III Montoya bone healing was observed on average at 13.6 months. There were two complications; one infection that required removal of the synthesis without disrupting the healing, and one re-fracture which was managed at a different service. CONCLUSIONS: An autologous half-tubular fibular graft, plus autologous and/or heterologous graft, stabilized with a UTN nail, restores the loss caused by the bone defect and allows achieving an appropriate bone healing.

Infection with Salmonella typhimurium has no effect on the composition and cleavage specificity of the 20S proteasome in human lymphoid cells.

Human leucocyte antigen (HLA)-B27 is strongly associated with spondyloarthropathies, including reactive arthritis. Several Gram-negative bacteria, such as Salmonella typhimurium, can trigger this disease. It has been suggested that peptides derived from bacterial proteins and presented by HLA-B27 to cytotoxic T lymphocytes might show molecular mimicry with autologous peptides, leading to T-cell cross-reaction and autoimmunity. Antigen presentation in Salmonella-infected cells could be modulated by changes in the composition of the proteasome, which is the major proteolytic system that generates major histocompatibility complex class I ligands. In this study we analysed whether the composition or activity of the 20S proteasome was altered upon infection of lymphoid cells by S. typhimurium. Two-dimensional gel electrophoresis failed to show any differences between the composition of 20S proteasomes from cells infected with S. typhimurium for 24 hr, relative to non-infected cells. In addition, digestions of oxidized insulin B-chain with purified 20S proteasomes from non-infected and infected cells generated the same products, indicating that the proteasomal cleavage specificity was not altered upon infection. These data indicate that infection of lymphoid cells by S. typhimurium fails to induce formation of immunoproteasomes or otherwise alter the proteolytic specificity of the 20S proteasome.

Sobre o processo de transmissão psicanalítica em um relatório de candidato do Instituto "Durval Marcondes" da SBPSP: investigação qualitativa

O presente estudo procura investigar os movimentos contidos na escrita do primeiro relatório, que compreendemos como resultado das influências teóricas e clínicas que o autor recebeu na sua formação analítica. Com a finalidade de formular hipóteses, desenvolvemos um diagrama que permite acompanhar através de signos lingüísticos os movimentos intersubjetivos e, portanto, refletir a análise do texto existente e, dessa forma, fazer correlações com os diversos pares envolvidos na situação psicanalítica: analista/analisando; analista/supervisor; analista/instituição; analista/texto e texto/leitor. A transmissão psicanalítica é sempre por nós entendida como um “processo”, de maneira que venha a envolver seus interlocutores pelo “novo” vértice psicanalítico. As bases epistemológicas, que o sujeito do Processo de Transmissão de Psicanálise (PTP) apresenta, precisam estar suficientemente enraizadas em sua personalidade para encontrar alguma ressonância no receptor. Sucintamente, estas bases estão relacionadas a: 1 — Compromisso com a Verdade Emocional; 2 — Relação Dinâmica com o Método Psicanalítico; 3 — Evolução da Comunicação entre os pares possíveis(AU)

Tratamiento de las rupturas antiguas del tendón de Aquiles con plastía de fascia de gemelos / Treatment for ancient ruptures of the heel cord by gastrocnemius fascia plasty

Objetivo. Se pretende la reconstrucción de aquel 20 a 30 por ciento de las rupturas aquileas que subsisten sin reparación. Material y métodos. Se trata de 19 casos, 13 varones y 6 mujeres, con edad promedio de 34.6 años, que tuvieron ruptura inveterada del tendón de Aquiles, espontánea en 13, por herida en tres y como re-ruptura postoperatoria en otros tres. La evolución promedio era de tres meses (33 a 202 días). En la cirugía, se regularizaron los extremos, sin resecar más de 2 mm de los extremos y preservando el tejido fibroso. Con el tobillo en equino, se suturo la ruptura término-terminal tipo Bunnell con nylon-00, reforzando con un colgado sural de 8-10 cm de largo y 1.5-2 cm de ancho, rotado y suturado con nylon-00 a todo lo largo sobre la reconstrucción. Se utiliza un yeso largo en equino por tres semanas y luego otro corto sin suela por otras tres. Se inicia rehabilitación, pero la marcha en equino se indica hasta los seis meses. Resultados. Fueron buenos en general, después de dos a 20 meses, con la salvedad de dos casos con ocho y 10 semanas. En todos se observó engrosamiento del tendón, hecho que se considera útil por incrementar su fuerza tensil. Como complicación sólo hubo un caso de dehiscencia superficial. Conclusión. Esta técnica se recomienda para las rupturas inveteradas del tendón de Aquiles, debiendo en todo caso respetar el término apropiado para su completa recuperación antes de forzar la rehabilitación.

Arteria coronaria única naciendo del seno de Valsalva derecho. A propósito de un caso / Single coronary artery from right Valsalva sinus. Apropos of a case

Las anomalías coronarias son una malformación poco frecuente, que según las series llega hasta 1,5 por ciento de los cateterismos cardíacos. Dentro de este grupo, la presencia de una arteria coronara única es extremadamente infrecuente, situándose en nuestra casuística en dos pacientes en 30.600 cateterismos cardíacos (0,066 por ciento). Uno de los principales problemas que plantea esta distribución es el elevado porcentaje de muerte súbita, que se asocia a los trayectos de la descendente anterior entre la aorta y la arteria pulmonar. Reportamos el caso de un paciente de 62 años, con coronaria única naciendo del seno derecho, con trayecto extremadamente infrecuente y la descendente anterior con curso entre los grandes vasos