Clima organizacional de enfermería en los hospitales regionales del Instituto de Previsión Social / Organizational climate of the regional hospitals of the Social Security Institute

El clima organizacional constituye uno de los factores determinantes de los procesos organizativos de gestión, cambio e innovación. Mantener niveles altos de satisfacción laboral permite mejorar procesos, fomentar el trabajo en equipo, aumentar la calidad y calidez de atención de enfermería y el rendimiento de su productividad, así como la satisfacción de los usuarios. El objetivo fue evaluar la percepción del clima organizacional de enfermería en los hospitales regionales del Instituto de Previsión Social (IPS), desde la perspectiva del enfermero/a asistencial. El mismo se realizó en base a parámetros cuantitativos, descriptivos y analíticos, utilizando una muestra de 188 enfermeras/os asistenciales que representa el 72% de la población total de enfermeros/as del área interior de ocho hospitales. Las variables del estudio fueron: características generales, condiciones de trabajo, infraestructura edilicia, integración organizacional, imagen del o la enfermero/a jefe, oportunidad de desarrollo profesional y compensación económica. La recolección de datos se llevó a cabo mediante la aplicación del instrumento “Encuesta de clima organizacional” utilizando la opción de selección múltiple para responder a los enunciados del mismo. Los resultados reflejaron la satisfacción en los siguientes factores: especialidad donde cumple funciones cada una de las enfermeras y la imagen gerencial de la enfermera jefe. Revelaron insatisfacción infraestructura edilicia, falta de cursos de capacitación como oportunidad para el desarrollo personal y profesional, inequidad salarial y falta de alcance de beneficios económicos adicionales al salario. El clima organizacional en los hospitales regionales se percibe, en general, como positivo porque existen posibilidades de modificar los factores que favorecen una mejora en las condiciones laborales.

CLOCK gene is implicated in weight reduction in obese patients participating in a dietary programme based on the Mediterranean diet.

INTRODUCTION: The success of obesity therapy is dependent on the genetic background of the patient. Circadian Locomotor Output Cycles Kaput (CLOCK), one of the transcription factors from the positive limb of the molecular clock, is involved in metabolic alterations. OBJECTIVE: To investigate whether five candidate polymorphisms from CLOCK were associated with anthropometric, metabolic measures and weight loss in response to a behavioural weight reduction programme based on the Mediterranean diet. METHODS: Five hundred overweight/obese subjects, aged 20-65 years, who attended outpatient clinics specializing in obesity, were studied. Anthropometric, biochemical and dietary intake variables were analysed. Effectiveness of the programme and weight loss progression during 28 weeks of treatment was assessed. RESULTS: Four of five CLOCK SNPs selected were significantly associated with obesity variables (P<0.05). The genetic variation in the rs1801260 CLOCK was associated with obesity at baseline and also affected weight loss. Patients with the variant allele (G) lost significantly less weight i(P=0.008) compared with wild type. Repeated measures analysis showed that weight loss over time was significantly different between rs1801260 CLOCK variations (P=0.038). Carriers of the G allele displayed greater difficulty in losing weight than non-carriers. In this particular polymorphism, the frequency of short-time sleepers (< or =6 h per day) was greater in minor allele carriers than in non-carriers (59% vs 41%; P<0.05). CLOCK polymorphisms were also associated with significant differences in total plasma cholesterol at the completion of dietary treatment (P<0.05). CONCLUSIONS: We have replicated previous studies showing a relationship between CLOCK gene polymorphisms and obesity. CLOCK rs1801260 SNP may predict the outcome of body weight reduction strategies based on low-energy diets.

[Comparison of dietary reference intakes (DRI) between different countries of the European Union, The United States and the World Health Organization]. / Comparativa de las Ingestas Dietéticas de Referencia (IDR) de los diferentes países de la Unión Europea, de Estados Unidos (EEUU) y de la Organización Mundial de la Salud (OMS).

BACKGROUND: In Spain, there are some organizations and scientific societies that have edited reference values of recommended nutrient intake, but whose data does not always agree in terms of format and content. AIMS: To review the definitions, data and methodology that other countries or groups of countries have followed to obtain and document their own reference values in order to offer basic information to facilitate the establishment of the best reference values for the Spanish population. FIELD: Review of the available information in different countries (or groups of countries) from the European Union, the United States and World Health Organization. The analysed data concerned to healthy populations. CONCLUSIONS: Reference intakes differ among the examined countries according to population groups, included nutrients, methodology and frequency of published reviews. However, most of the countries define major concepts in the same way, although with different names in each country. On the other hand, most of the studied cases represent only a scientific organization in charge of the publication and update of the values of dietary reference intakes, but not in Spain. In that context, it looks convenient to reach a consensus among all Spanish organizations and scientific societies that are involved in this task, in order to establish an acceptable reference values.

Comparativa de las Ingestas Dietéticas de Referencia (IDR) de los diferentes países de la Unión Europea, de Estados Unidos (EEUU) y de la Organización Mundial de la Salud (OMS) / Comparison of dietary reference intakes (DRI) between different countries of the European Union, The United States and the world health organization

Antecedentes: En España, existen varios organismos y sociedades científicas que han editado sus propios de valores de referencia sobre la ingesta recomendada de nutrientes, que no siempre coinciden en los contenidos y formas presentadas. Objetivo: Revisar los conceptos, datos y la metodología que han seguido otros países o grupos de países para obtener y documentar sus propios Valores de Referencia, con objeto de ofrecer una información básica que facilite el establecimiento de los valores de referencia que mejor puedan adaptarse a la población española, en base a la mejor evidencia científica disponible en la actualidad. Ámbito: Revisión de la información disponible en los distintos países (o grupos de países) de la Unión Europea, Estados Unidos y la Organización Mundial de la Salud. Los datos estudiados corresponden a poblaciones sanas. Conclusiones: Las ingestas de referencia difieren notablemente entre los distintos países estudiados en cuanto a grupos de población, tipo de nutrientes incluidos, metodología y periodicidad de las revisiones publicadas. Sin embargo, la mayoría definen de manera semejante los conceptos más importantes, aunque tengan distintas denominaciones en cada país. Por otro lado, en la mayoría de los casos estudiados existe un único organismo científico encargado de la publicación y actualización de los valores de ingestas dietéticas de referencia, no siendo así en España. En este contexto, parece conveniente alcanzar un acuerdo entre todos los organismos y sociedades científicas españolas implicadas en esta tarea, con objeto de establecer unos valores de referencia únicos para todo el país, con el consenso de todos (AU)

Background: In Spain, there are some organizations and scientific societies that have edited reference values of recommended nutrient intake, but whose data does not always agree in terms of format and content. Aims: To review the definitions, data and methodology that other countries or groups of countries have followed to obtain and document their own reference values in order to offer basic information to facilitate the establishment of the best reference values for the Spanish population. Field: Review of the available information in different countries (or groups of countries) from the European Union, the United States and World Health Organization. The analysed data concerned to healthy populations. Conclusions: Reference intakes differ among the examined countries according to population groups, included nutrients, methodology and frequency of published reviews. However, most of the countries define major concepts in the same way, although with different names in each country. On the other hand, most of the studied cases represent only a scientific organization in charge of the publication and update of the values of dietary reference intakes, but not in Spain. In that context, it looks convenient to reach a consensus among all Spanish organizations and scientific societies that are involved in this task, in order to establish an acceptable reference values (AU)

Effectiveness of cognitive-behavioral therapy based on the Mediterranean diet for the treatment of obesity.

OBJECTIVE: The Mediterranean dietary pattern improves cardiovascular disease factors. More research is needed on the usefulness of a Mediterranean dietary pattern in terms of weight loss. The objective of this study was to assess the effectiveness of behavioral therapy based on the Mediterranean diet for the treatment of obesity and to determine the main obstacles to weight loss. METHODS: A total of 1406 obese subjects (body mass index, 31+/-5kg/m(2)), aged 20-65 y, from a Mediterranean area in southeast Spain were subjected to a weight-reduction program. To evaluate effectiveness, weight loss, body fat distribution, biochemical variables, blood pressure changes, mean duration of treatment, percentage of attrition, and the ability to fulfill a Mediterranean diet pattern were assessed. To determine the main barriers to losing weight, a "Barriers to Weight Loss" checklist was completed. RESULTS: The behavioral therapy program was effective for the treatment of obesity. The average weight loss was 7.7kg. The duration of treatment was 34 wk. Eighty-nine percent of subjects fulfilled the Mediterranean principles during the program, and all the variables studied were significantly improved. Attrition was 4-9%, with the main reason being stress (37%). Main obstacles to weight loss were "losing motivation," being "prone to stress-related eating," and being liable to eat when bored. Recording food intake and assisting group therapy were also important tools for losing weight (P< or =0.05). CONCLUSIONS: Dietary/behavioral treatment based on Mediterranean dietary principles is effective in clinical practice. Nutrition professionals should encourage their patients to record food intake and to attend group therapy.

Influence of two polymorphisms of the tumoral necrosis factor-alpha gene on the obesity phenotype.

Several populational-based studies have suggested an association between tumoral necrosis factor-alpha (TNF-alpha) polymorphisms and obesity-related phenotypes. Therefore, this study aimed at assessing the situation (frequency and associated phenotype) of two TNF-alpha common polymorphisms in a Spanish population. In a case-control design study, a group of Spanish subjects (n=313) were genotyped for the TNF-alpha G/A -308 and -238 polymorphisms. Obese subjects (cases) were compared with lean individuals (controls) according to body mass index (BMI; cases: BMI >30 kg/m2, controls: BMI <25 kg/m2). Waist-to-hip ratio, body composition and some metabolic indicators were assessed. The frequency of the -308A allele (0.14) and -238A allele (0.09) was similar to those previously reported in other Caucasian populations. Interestingly, cases with the -308A allele of the TNF-alpha gene have significantly higher hip and waist circumferences (p<0.05), BMI (p<0.01) and body fat mass (p<0.05) values than obese individuals carrying the -308G allele, but not the waist-to-hip ratio. No apparent influence of the -308A polymorphism on other metabolic indicators (insulin and leptin levels) was found. We could not detect any association between the substitution at position -238 polymorphism of the TNF-alpha gene and obesity anthropometrical phenotypes in this Spanish population, despite some differences in plasma leptin. These results support the hypothesis that the G/A -308 polymorphism of the TNF-alpha gene is associated with a higher BMI as well as hip ad waist circumferences, particularly on female bearers, while no influence on such measurements was found for the G/A -238 TNF-alpha gene polymorphism, but only an effect on leptinaemia.

Polimorfismos genéticos en TNFalfa y PPARgamma2 y síndrome de resistencia a insulina

El síndrome de resistencia insulínica aparece como consecuencia de la interacción de factores genéticos y ambientales. Entre los primeros se ha descrito la influencia que ejercen determinados polimorfismos sobre la sensibilidad a la insulina. Con objeto de conocer el efecto que tienen ciertos polimorfismos en los genes de TNFalfa y PPARgamma2 sobre los componentes del síndrome de insulinresistencia en nuestra población, hemos estudiado 313 personas 159 obesos y 154 con peso normal, con un diseño casos-controles, a los que se ha practicado: valoración de medidas antropométricas y TA, analítica plasmática de: glucosa, perfil lipídico, insulina y leptina, índice HOMA y análisis genético para los polimorfismos -238 G/A y -308 G/A en la región promotora del gen de TNFalfa y el polimorfismo Pro 12A1a en el gen de PPARgamma2. Resultados: La frecuencia alélica y prevalencia de los mencionados polimorfismos en nuestros pacientes fueron las esperadas. Los obesos, en su conjunto, mostraron valores significativamente más bajos de HDL colesterol y más elevados en todos los parámetros restantes. Los obesos que presentaban la mutación -308 A en el gen de TNFalfa tenían mayores IMC y por ciento de grasa corporal que aquellos sin esa mutación. Los obesos que presentaban la mutación -238A en el gen de TNFalfa tenían menores: índice HOMA, TA diastólica y niveles de leptina. Los obesos que presentaban la mutación A1a 12 en el gen de PPARy2 tenían menores niveles de insulina e índice HOMA. Conclusión: El polimorfismo -308 A en el gen de TNFalfa se asocia con mayor obesidad aunque no con mayor resistencia a la insulina mientra que los polimorfismos -238 A en TNFa y Prol2Aaa en PPARy2 se acompañan de mayor sensibilidad a la insulina (AU)

[Influence of the polymorphism 03826 A --> G in the UCP1 gene on the components of metabolic syndrome]. / Influencia del polimorfismo -3826 A --> G en el gen de la UCP1 sobre los componentes del síndrome metabólico.

BACKGROUND: The uncoupling protein UCP1 has been related to the development and/or maintenance of obesity through its involvement in regulating energy balance. The role of this mitochondrial protein in humans is uncertain due to the scarce presence of the brown adipose tissue in the adult individual. The polymorphism -3826 A/G of the UCP1 alone or in conjunction with the mutation Trp64Arg of the adrenergic receptor b3 has been associated with obesity, diabetes mellitus and related diseases although with contradictory results. With the aim of determining the influence of polymorphism -3826 A/G of the UCP1 on the classical components of the metabolic syndrome in our population, we studied 159 obese individuals and 154 of normal weight, with a study design of cases and controls. In all of them Body Mass Index (BMI), hip/waist index, % of body fat, arterial tension (AT), lipidic profile, leptine, basal glucemia and basal insulinemia were determined. Similarly, the presence of the above mentioned mutation of the UCPI gene was analysed. RESULTS: Significant differences were obtained in all of the variables studied between obese (cases) and normal weight (controls). Within the obese group, polymorphism -3826 A/G of the UCP1 gene (n=53) was associated with a greater BMI (p=0.03), greater percentage of body fat (p=0.04) and higher AT both systolic (p=0.009) and diastolic (p=0.02). There were no statistically significant differences in any of the other indices evaluated. CONCLUSION: The fundamental factor that influences the components of the metabolic syndrome is obesity. However, the polymorphism -3826 A/G of the UCP1 gene is associated with a greater degree of obesity and very high figures of AT.

Influencia del polimorfismo -3826 A --> G en el gen de la UCP1 sobre los componentes del síndrome metabólico / Influence of the polymorphism 03826 A --> G in the UCP1 gene on the components of metabolic syndrome

Fundamento. La proteína desacoplante UCP1 se ha relacionado con el desarrollo y/o mantenimiento de la obesidad a través de su implicación en la regulación del balance energético. El papel de esta proteína mitocondrial en humanos es incierto por la escasa presencia del tejido adiposo pardo en el individuo adulto. El polimorfismo -3826 A/G de la UCP1 solo o conjuntamente con la mutación Trp64Arg del receptor adrenérgico Beta3 se ha asociado con obesidad, diabetes mellitus y enfermedades relacionadas aunque con resultados contradictorios. Con objeto de conocer la influencia del polimorfismo 3826 A/G de la UCP1 sobre los componentes clásicos del síndrome metabólico en nuestra población, se han estudiado 159 individuos obesos y 154 en normopeso, con un diseño de casos y controles. A todos ellos se les ha determinado IMC, índice cintura/cadera, por ciento de grasa corporal, TA, perfil lipídico, leptina, glucemia e insulinemia basales. Asimismo se les ha analizado la presencia de la mencionada mutación en el gen de la UCP1.Resultados. Se obtuvieron diferencias significativas en todas las variables estudiadas entre obesos (casos) y normopeso (controles) Dentro del grupo de obesos, el polimorfismo -3826 A/G del gen de la UCP1 (n=53) se asoció con un mayor IMC (p=0,03), mayor por ciento de grasa corporal (p=0,04) y TA más elevada tanto sistólica (p=0,009) como diastólica (p=0,02) No hubo diferencias estadísticamente significativas en ninguno de los demás índices evaluados. Conclusión. El factor fundamental que influye sobre los componentes del síndrome metabólico es la obesidad.No obstante, el polimorfismo -3826 A/G del gen de la UCP1 se asocia con un mayor grado de obesidad y unas cifras más elevadas de TA (AU)

A novel nonsense mutation in the melanocortin-4 receptor associated with obesity in a Spanish population.

BACKGROUND: In recent years, several groups have reported dominant inheritance of obesity conferred by missense, nonsense and frameshift mutations in the melanocortin 4 receptor gene (MC4R). Hence, MC4R is involved in the most common monogenic form of human obesity described so far. OBJECTIVES: In this context, we screened a Spanish population, composed of obese subjects and normal weight controls, for mutations in the MC4-R by single-strand conformational polymorphism (SSCP). SUBJECTS AND METHODS: Overall 313 individuals, 159 obese subjects (body mass index: BMI: 37.6 kg/m(2), 95% CI: 36.7-38.5 kg/m(2)) and 154 normal weight control subjects (BMI: 22.3 kg/m(2), 95% CI: 22.0-22.6 kg/m(2)) were screened for MC4-R mutations. RESULTS: We detected a novel nonsense mutation at codon 16 of the MC4-R in an obese female (BMI: 30.0 kg/m(2)) and a previously described missense mutation (Val-253-Ile) located within the sixth trans-membrane domain of the MC4-R in a normal weight individual (BMI: 19.0 kg/m(2)). The polymorphism Val-103-Ile was detected in one obese individual, while four subjects (two cases and two controls) with the polymorphism Ile-251-Leu were found. CONCLUSIONS: We have identified a novel nonsense mutation (Trp-16-Stop) that, based on previously described frameshift and nonsense mutations, most likely results in dominantly inherited obesity. Within this Spanish population, the frequency of the Ile-251-Leu polymorphism of the MC4R was similar in obese and control subjects (about 1.3%), while the polymorphism Val-103-Ile was only detected in an obese individual (0.6%).

TRP64ARG polymorphism of the beta 3-adrenergic receptor gene and obesity risk: effect modification by a sedentary lifestyle.

AIM: We performed a case-control study to assess the association between obesity risk and the Trp64Arg polymorphism of the beta 3-adrenergic receptor gene. METHODS: Obese subjects [n = 159; body mass index (BMI) > 30 kg/m2] and controls (n = 154; BMI < 25 kg/m2) were compared using multivariable logistic regression to control for potential confounders. RESULTS: A higher obesity risk (adjusted OR: 2.98; 95% CI: 1.00-8.56; p = 0.05) was associated with the Trp64Arg polymorphism among sedentary, but not among more active people. CONCLUSIONS: Our results suggest that the TRP64ARG polymorphism of the ADRB3 seems to be a risk factor for obesity that is dependent on a sedentary lifestyle.

The risk of obesity and the Trp64Arg polymorphism of the beta(3)-adrenergic receptor: effect modification by age.

AIM: To examine the association between the risk of obesity and the Trp64Arg polymorphism of the beta(3)-adrenergic receptor gene. METHODS: A case-control study was conducted. The case series encompassed 159 subjects with a body mass index >30 kg/m(2) (obesity) and no other major diseases except for type 2 diabetes, and the controls were 154 healthy subjects with a body mass index <25 kg/m(2). 313 Spanish subjects between 20 and 60 years of age were screened for the Trp64Arg mutation. RESULTS: The prevalence of the Trp64Arg mutation was similar among cases (19.5%) and control subjects (16.2%). The association between the risk of obesity and the Trp64Arg mutation was estimated using multivariate logistic regression. A higher odds ratio of 3.84 (95% CI 1.33-11.12) for the mutation was found among younger individuals (20-35 years), while no increased risk was apparent among older participants (35-60 years). Moreover, when the model was adjusted for gender, age, and leisure-time physical activity, the product-term for interaction (effect modification) between age and the presence of the Trp64Arg mutation was statistically significant (likelihood ratio test p = 0.035). CONCLUSION: Individuals aged 20-35 years who are Trp64Arg carriers had a substantially higher risk of developing obesity, independent of their sex or leisure-time physical activity.

Beta(2)-adrenergic receptor mutation and abdominal obesity risk: effect modification by gender and HDL-cholesterol.

OBJECTIVE AND DESIGN: A case-control study was conducted to examine the association between the 27Glu polymorphism of the beta(2)-adrenergic receptor gene (ADRB2) and the risk of abdominal obesity (defined by a waist/hip ratio: WHR higher than 0.85). METHODS: The case series encompassed 112 obese subjects with body mass index (BMI) > 30 kg/m(2) and WHR > 0.85 and no other major disease except for type 2 diabetes, while the controls were 127 healthy subjects, BMI < 25 kg/m(2) and WHR < 0.85. RESULTS: The association between the risk of abdominal obesity and the 27Glu polymorphism was estimated using multivariate logistic regression. A higher crude odds ratio (OR) of 4.08 (95 % confidence interval: 0.98-16.3) for the 27Glu allele was found among men, while no increased risk was apparent among female participants. Moreover, when the model was adjusted for age, male subjects carriers of the 27Glu allele had a significant ten-fold higher risk of abdominal obesity (OR = 10.31; 95 % CI: 1.4-76.8) and the product-term for the interaction (effect modification) between gender and the ADRB2 mutation was near to the limits of statistical significance (Likelihood ratio test p = 0.056). Interestingly, we also found an effect modification with higher OR among individuals with low HDL-cholesterol (< 1.5 mmol/l) after adjustment for age and gender (OR = 2.87 95 % CI 1.09-7.50) and the product-term for interaction between the 27Glu allele and HDL-cholesterol was statistically significant (Likelihood ratio test p = 0.003). CONCLUSIONS: Our results showed that the 27Glu allele of the ADRB2 gene appears to be a risk factor for abdominal obesity among male subjects, specially among those with lower HDL-cholesterol levels.

High-fat feeding reduced muscle uncoupling protein 3 expression in rats.

Uncoupling Protein 3 (UCP3), largely expressed in skeletal muscle, is modulated by cold, thyroid hormones, leptin, fasting-refeeding and exercise training among other factors in a tissue-specific manner. In brown adipose tissue, there is an increase in UCP3 levels after high-fat feeding and beta3-adrenergic agonist treatment. Controversial effects of these agents have been reported in skeletal muscle. The aim of this experimental trial was to evaluate the effect of high-fat feeding and beta3-adrenergic agent treatment on skeletal muscle UCP3 expression levels. Lean rats were fed a cafeteria diet for 30 days and found to have significantly higher fat stores and body weight than control rats at the end of the experimental period. When cafeteria-diet rats were daily i.p. injected with Tertatolol for 30 days; a decrease in total fat mass and body weight was found. Such an effect was not observed in fa/fa rats. Interestingly, gastrocnemius muscle UCP3 mRNA levels were significantly reduced in cafeteria-diet rats when compared to lean animals. Likewise, mitochondrial O2 consumption in gastrocnemius muscle was also significantly decreased (-31%) in cafeteria-diet rats as compared to the control group. It is suggested that the down-regulation of UCP3 gene expression together with the lower O2 consumption observed in high fat fed rats may be linked to lower fatty oxidation, which would promote triglyceride accumulation.

Interactions between bradykinin and ANP in rat kidney in vitro: inhibition of natriuresis and modulation of medullary cyclic GMP.

In anesthetized rats, the renal excretory actions of atrial natriuretic peptide (ANP) are inhibited by intravenous or intraperitoneal injections of bradykinin. To elucidate the mechanisms underlying this inhibition, we evaluated bradykinin effects on: i- ANP-induced natriuresis and diuresis in isolated perfused rat kidneys, and ii- ANP-induced cGMP production in rat renal medulla in vitro. In perfused kidneys, 1 microgram bradykinin completely inhibited the diuretic and natriuretic responses elicited by 0.5 microgram ANP, without changes in perfusion pressure. The inhibitory effects of bradykinin were abolished by HOE-140, a kinin-B2 receptor antagonist. Bradykinin alone had no effect on urinary excretion or perfusion pressure. Incubation with ANP (0.1 nM to 1 microM) increased renal medullary cGMP content up to 30-fold, in a concentration-dependent fashion. Medullary cGMP was moderately increased by the nitric oxide donor, sodium nitroprusside (1 microM), but it was unchanged by bradykinin (0.1 nM-0.1 microM). Despite this, ANP-induced cGMP production was significantly enhanced by co-incubation with low concentrations of bradykinin (up to 0.1 nM). In contrast, ANP-induced cGMP accumulation was unchanged by concentrations of 1 nM bradykinin or higher. In the presence of 100 nM HOE-140, bradykinin (0.1-1 nM) did not affect ANP-induced cGMP production. These results demonstrate that bradykinin counteracts ANP-stimulated sodium and water excretion, by acting directly on the kidney. The interaction between both peptides is complex; our data suggest that renal medullary ANP receptors are subjected to an on/off modulation by fluctuating bradykinin concentrations.

Rotura espontánea del hígado y quiste hidatídico hepático roto a vía biliar asociados a embarazo / Spontaneous hepatic rupture and hydatid hepatic cyst rupture to biliary tract associated to pregnancy

Se presentan dos casos clínicos, el primero corresponde a una rotura espontánea de hígado asociada a gestación de 25 semanas con hipertensión arterial crónica y preeclampsia severa sobreagregada y el segundo a quiste hidatídico hepático complicado, roto a vía biliar concomitante con gestación de 36 semanas. Se revisa la literatura y se discute el manejo quirúrgico en ambos casos