Microstructured click hydrogels for cell contact guidance in 3D.

The topography of the extracellular matrix (ECM) is a major biophysical regulator of cell behavior. While this has inspired the design of cell-instructive biomaterials, the ability to present topographic cues to cells in a true 3D setting remains challenging, particularly in ECM-like hydrogels made from a single polymer. Herein, we report the design of microstructured alginate hydrogels for injectable cell delivery and show their ability to orchestrate morphogenesis via cellular contact guidance in 3D. Alginate was grafted with hydrophobic cyclooctyne groups (ALG-K), yielding amphiphilic derivatives with self-associative potential and ionic crosslinking ability. This allowed the formation of microstructured ALG-KH hydrogels, triggered by the spontaneous segregation between hydrophobic/hydrophilic regions of the polymer that generated 3D networks with stiffer microdomains within a softer lattice. The azide-reactivity of cyclooctynes also allowed ALG-K functionalization with bioactive peptides via cytocompatible strain-promoted azide-alkyne cycloaddition (SPAAC). Hydrogel-embedded mesenchymal stem cells (MSCs) were able to integrate spatial information and to mechano-sense the 3D topography, which regulated cell shape and stress fiber organization. MSCs clusters initially formed on microstructured regions could then act as seeds for neo-tissue formation, inducing cells to produce their own ECM and self-organize into multicellular structures throughout the hydrogel. By combining 3D topography, click functionalization, and injectability, using a single polymer, ALG-K hydrogels provide a unique cell delivery platform for tissue regeneration.

Mesenchymal Stem Cells: Case Report of an Adjuvant Ambulatory Therapy for a COVID-19 High-Risk and Steroid-hypersensitive Patients.

INTRODUCTION: Due to the rapid progression of COVID-19 to severe and critical stages, thousands of patients have required the use of intensive care unit (ICU) treatment, placing an excessive strain on health systems. Immunomodulatory effects of Wharton's Jelly Mesenchymal Stem Cells (WJ-MSCs) have shown promising results in the treatment of patients with COVID-19. However, the effect of promptly applied cell therapy on ambulatory patient prognosis has not been described. This case report presents the clinical outcome of a multimorbid, steroid-hypersensitive, COVID-19 patient treated with WJ-MSCs transplantation. CASE PRESENTATION: A 67-year-old woman with Type 2 diabetes, overweight (82 kg, 168 cm, BMI = 29.053), hypertension (190/60 mmHg) and steroid-hypersensitivity, tested positive for COVID-19 after presenting typical symptoms such as fatigue, chest pain, myalgia, nasal congestion, dysgeusia, anosmia and oxygen saturation (SpO2) 94% - 96%, with normal body temperature (36°C). The patient received pharmacologic treatment but, when symptoms worsened, WJ-MSCs were transplanted to modulate the suspected onset of the cytokine release syndrome. Significant improvement of symptoms and clinical parameters (inflammatory markers and CT score) was observed, and the patient fully recovered within a short period of time. CONCLUSION: The present case report exhibits the favorable outcome of using Wharton's Jelly Mesenchymal Stem Cells (WJ-MSCs) as an ambulatory and adjuvant therapy for COVID-19. Prompt WJ-MSCs infusion can be a safe ambulatory adjuvant therapy in COVID-19 infection care, preventing disease progression to critical stages and avoiding hospital overcrowding.

High prevalence of chronic malnutrition in indigenous children under 5 years of age in Chimborazo-Ecuador: multicausal analysis of its determinants.

BACKGROUND: Despite the multiple initiatives implemented to reduce stunting in Ecuador, it continues to be a public health problem with a significant prevalence. One of the most affected groups is the rural indigenous population. This study aimed to analyze the prevalence of chronic malnutrition in indigenous children under 5 years of age and its association with health determinants, focusing on one of the territories with the highest prevalence of stunting. METHODS: A cross-sectional study in 1,204 Kichwa indigenous children under the age of five, residing in rural areas of the counties with the highest presence of indigenous in the province of Chimborazo-Ecuador. A questionnaire on health determinants was applied and anthropometric measurements were taken on the child and the mother. Stunting was determined by the height-for-age z-score of less than 2 standard deviations, according to the World Health Organization´s parameters. Data were analyzed using bivariate and multivariate Poisson regression. RESULTS: 51.6% (n = 646) of the children are stunted. Height-for-age z-scores were significantly better for girls, children under 12 months, families without overcrowding, and families with higher family income. The variables that were significantly and independently associated with stunting were: overcrowding (PR 1.20, 95% CI 1-1.44), the mother required that the father give her money to buy medicine (PR 1.33, 95% CI 1.04-1.71), the father did not give her money to support herself in the last 12 months (1.58, 95% CI 1.15-2.17), mother's height less than 150 cm (PR 1.42, 95% CI 1.19-1.69) and the child was very small at birth (PR 1.75, 95% CI 1.22-2.5). CONCLUSION: One out of every two rural indigenous children included in this study is stunted. The high prevalence of stunting in the indigenous and rural population is multicausal, and requires an intersectoral and multidisciplinary approach. This study identified three fundamental elements on which public policy could focus: (a) reduce overcrowding conditions, improving economic income in the rural sector (for example, through the strengthening of agriculture), (b) provide prenatal care and comprehensive postnatal care, and (c) promote strategies aimed at strengthening the empowerment of women.

Breastfeeding, feeding practices and stunting in indigenous Ecuadorians under 2 years of age.

BACKGROUND: The indigenous child population in Ecuador has a high prevalence of stunting. There is limited evidence of the association between breastfeeding, feeding practices, and stunting in indigenous children. This study aimed to analyze the prevalence of breastfeeding and complementary feeding practices and explore their association with stunting in Ecuadorian indigenous children under two years of age. METHODS: Cross-sectional study of secondary data analysis using the 2012 Ecuador National Health and Nutrition Study, in 625 children aged 0-23 months (48,069 expanded sample), representative for the indigenous population. Breastfeeding and complementary feeding indicators were analyzed by age groups. Timely initiation of breastfeeding (within one hour after birth), exclusive breastfeeding (infants under six months who received only breast milk for the previous day), and other indicators were measured. Chi-square test or Fisher's exact test and logistic regression for complex samples were used to explore association with demographic and socioeconomic factors and stunting. RESULTS: Twenty-six-point eight percent of the children were stunted. Stunting occurred mainly in children with rural residence, on poor households, and where there were four or more children. Most of the children had a timely initiation of breastfeeding (69.5% for 0-12 months and 75.5% for 13-23 months) and exclusive breastfeeding up to six months (78.2%). Among children between 6-12 months of age, 99.3% continued to be breastfed. In children from ages 6 to 12 months, 32.5% received food with adequate dietary diversity. Lower percentages of complementary feeding occurred in the poorest, adolescent mothers or those with less education. Children who did not receive the minimum frequency of meals for their age had higher odds of stunting (OR 3.28; 95% CI 1.3, 8.27). Children from age 19 to 23 months who consumed foods rich in iron showed lower probabilities of stunting (OR 0.04; 95% CI 0.00, 0.51). CONCLUSIONS: Breastfeeding practices reached a prevalence of 70% or more, without being associated with stunting. Complementary feeding practices showed differences by socioeconomic condition. Not reaching the minimum meal frequency between 6 and 12 months of age was associated with stunting. Plans and strategies are necessary to promote adequate feeding and breastfeeding practices in the indigenous population.

Engineering injectable vascularized tissues from the bottom-up: Dynamics of in-gel extra-spheroid dermal tissue assembly.

Modular tissue engineering approaches open up exciting perspectives for the biofabrication of vascularized tissues from the bottom-up, using micro-sized units such as spheroids as building blocks. While several techniques for 3D spheroid formation from multiple cell types have been reported, strategies to elicit the extra-spheroid assembly of complex vascularized tissues are still scarce. Here we describe an injectable approach to generate vascularized dermal tissue, as an example application, from spheroids combining fibroblasts and endothelial progenitors (OEC) in a xeno-free (XF) setting. Short-term cultured spheroids (1 day) were selected over mature spheroids (7 days), as they showed significantly higher angiogenic sprouting potential. Embedding spheroids in fibrin was crucial for triggering cell migration into the external milieu, while providing a 3D framework for in-gel extra-spheroid morphogenesis. Migrating fibroblasts proliferated and produced endogenous ECM forming a dense tissue, while OEC self-assembled into stable capillaries with lumen and basal lamina. Massive in vitro interconnection between sprouts from neighbouring spheroids rapidly settled an intricate vascular plexus. Upon injection into the chorioallantoic membrane of chick embryos, fibrin-entrapped pre-vascularized XF spheroids developed into a macrotissue with evident host vessel infiltration. After only 4 days, perfused chimeric capillaries with human cells were present in proximal areas, showing fast and functional inosculation between host and donor vessels. This method for generating dense vascularized tissue from injectable building blocks is clinically relevant and potentially useful for a range of applications.

Social capital and its relationship with malnutrition and anemia in children from rural coastal Ecuador.

INTRODUCTION: Social capital is considered an important determinant of health and overall wellbeing; however, to the best of the authors' knowledge, literature relating social capital to malnutrition in developing countries is still relatively small. This article examines the relationships between social capital and chronic malnutrition and anemia in a population of rural coastal children in Ecuador. METHODS: A cross-sectional study in two groups of 246 and 282 children under 5 years and their families was performed. Anemia and chronic malnutrition were analyzed as outcome variables. Variables about social capital were identified on the basis of the Social Capital Assessment Tool of the World Bank. Bivariate and multivariate logistic regression analyses were conducted. RESULTS: The prevalences of anemia and chronic malnutrition in the children were 15.0% and 12.8%, respectively. At the multivariate analysis, the variable 'mother has borrowed money' had an inverse association with chronic malnutrition (prevalence ratio (PR) 0.43, 95% confidence interval (CI) 0.20-0.90). Receiving and providing help after the earthquake of 2016 was significantly associated with a lower prevalence of chronic malnutrition (PR 0.52, 95%CI 0.28-0.97), but not with anemia. However, a mother being part of a community organization was associated with a 1.90 times higher prevalence of anemia (95%CI 1.04-3.48) in children than mothers who were not part of a community organization. CONCLUSION: The relationship between maternal social capital and the nutritional status of their children in rural communities seems to be positively related. However, a mother's participation in community organizations increases the prevalence of anemia in the children. These mixed results highlight the need for further studies focused on the different types of social capital and how they impact on health in deprived areas.

Capital social y malnutrición en población indígena menor de 5 años de cinco cantones de la provincia de Chimborazo / Social capital and malnutrition in the indigenous population under 5 years of age in five cantons of the province of Chimborazo

Introducción: El capital social (CS) incluye varios componentes de la organización social, que podrían mejorar la situación de salud. Existe poca información sobre su asociación con la Desnutrición Crónica (DC). Metodología: El presente estudio transversal analítico fue realizado en los cantones de Riobamba, Alausí, Guamote, Guano y Colta en el periodo 2018-2019. Con una muestra probabilística mediante encuestas a madres/cuidadores se determinó el CS, determinantes de la salud, y mediciones antropométricas. El análisis de datos se realizó mediante regresión bivariada y multivariada, con cálculo de Odds e intervalos de confianza al 95 %, se consideró significativo un valor de p menor a 0.05, se utilizó el software SPSS versión 25.0. Resultados: Se estudiaron 1228 niños, el 50.5% (n = 620) hombres y 49.5% (n= 680) mujeres. Con DC el 52.6% (n = 326) de los hombres y el 46.7% (n = 284) de las mujeres. Los hijos cuyos padres no han escuchado hablar sobre desnutrición infantil presentaron un OR 1.46 (IC95%=1.13-1.9) para el desarrollo de DC. Esta asociación se mantuvo significativa después del ajuste por sexo, edad del niño/a, número de hijos e ingresos económicos. Conclusiones: La asociación entre el CS y la DC en la población indígena menor de 5 años de la provincia de Chimborazo se observó en la falta de información sobre nutrición infantil.

Introduction: Social capital (SC) includes several components of social organization, which could improve the health situation. There is little information on its association with chronic malnutrition. Methods: Cross-sectional and analytical study in 1228 indigenous children under 5 years of age from the Riobamba, Alausí, Guamote, Guano and Colta cantons, in the province of Chimborazo. Surveys were conducted with mothers / caregivers on SC, to assess the dimensions: trust and solidarity, collective action and cooperation, information, communication and social cohesion. Anthropometric measurements were made to the children to determine chronic malnutrition. Data analysis was performed using bivariate and multivariate regression, with calculation of Odds Ratio and 95% confidence intervals, a value of p less than 0.05 was considered significant. SPSS software version 25.0 was used. Results: 50.5% (n = 620) of the children studied were men and 49.5% (n = 680) were women. 52.6% (n = 326) of men and 46.7% (n = 284) of women presented chronic malnutrition. Children whose parents have not heard about child malnutrition were 1.46 (95% CI = 1.13-1.9) times more likely to have chronic malnutrition compared to those who did. This association remained significant after adjusting for sex, age of the child, number of children, and income. Conclusions: The association between CS and chronic malnutrition in the indigenous population under 5 years of age in the province of Chimborazo was observed in the lack of information on child nutrition

Occupational exposure to organophosphorus and carbamates in farmers in La Cienega, Jalisco, Mexico: oxidative stress and membrane fluidity markers.

BACKGROUND: The region of La Cienega in Jalisco Mexico, is an important agricultural reference for the production of corn, sorghum and wheat, among other grains, so the use of pesticides for pest control is high. However, in this rural area there are no toxicological studies that assess the occupational risk of pesticide use. Therefore, this study is the first to determine the oxidative stress levels markers (GSH, GSSG, carbonyl groups, nitric oxide metabolites and lipid peroxides) as well as alteration of the mitochondrial membrane fluidity caused by occupational exposure to organophosphorus and carbamates in farmers of this region. This occupational risk can increase cellular oxidation, which explains the high prevalence of neurodegenerative diseases and cancer in Cienega settlers to be analyzed in future studies. METHODS: Comparative cross-sectional study was performed using two groups: one not exposed group (n = 93) and another one with occupational exposure (n = 113). The latter group was sub-divided into 4 groups based on duration of use/exposure to pesticides. Oxidative stress levels and membrane fluidity were assessed using spectrophotometric methods. Statistical analyses were performed using SPSS software ver. 19.0 for windows. RESULTS: The most commonly used pesticides were organophosphorus, carbamates, herbicide-type glyphosate and paraquat, with an average occupational exposure time of 35.3 years. There were statistically significant differences in markers of oxidative stress between exposed farmers and not exposed group (p = 0.000). However, in most cases, no significant differences were found in markers of oxidative stress among the 4 exposure sub-groups (p > 0.05). CONCLUSION: In the Cienega region, despite the indiscriminate use of organophosphorus and carbamates, there are no previous studies of levels oxidative stress. The results show increased levels of oxidative stress in occupationally exposed farmers, particularly membrane fluidity levels increased three times in contrast to not exposed group.

A Multi-causal Model for Chronic Malnutrition and Anemia in a Population of Rural Coastal Children in Ecuador.

OBJECTIVES: Chronic malnutrition and anemia are prevalent in developing countries. This research aimed to determine the prevalence of chronic malnutrition and anemia and their associated factors in children under five using a multi-causal model in a rural community in the coast of Ecuador. METHODS: The study included 314 children under 5 years old who were residents of San Isidro, Ecuador. Indicators of chronic malnutrition and anemia were identified. Mothers/caregivers were surveyed on socio-economic and environmental conditions, feeding and care practices, access to health services and biological characteristics. Bivariate and multivariable Poisson regression were performed. RESULTS: The prevalence was 12.42% (n = 39) for chronic malnutrition and 16.98% (n = 54) for anemia. There was a significant and independent association between chronic malnutrition and family income less than $80 USD per month (Prevalence Ratio [PR] = 2.74, 95% CI 1.04, 7.20), maternal height less than 150 cm (PR 3.00, 95% CI 1.69, 5.32) and residence in a household with more than 4 children (PR 3.05, 95% CI 1.48, 6.29). Anemia was 2.57 times higher (95% CI 1.17, 5.65) in children with more than two episodes of diarrhea in the last 6 months. Prenatal care (5 to 8 visits) provided a protective effect for anemia (PR 0.48, 95% CI 0.27, 0.89). CONCLUSIONS FOR PRACTICE: Findings support the need for comprehensive interventions targeted toward chronic malnutrition and anemia in children from rural coastal communities. Improvement of socioeconomic conditions, family planning, prenatal care and reduction of diarrheal diseases should be prioritized.

Chitosan drives anti-inflammatory macrophage polarisation and pro-inflammatory dendritic cell stimulation.

Macrophages and dendritic cells (DC) share the same precursor and play key roles in immunity. Modulation of their behaviour to achieve an optimal host response towards an implanted device is still a challenge. Here we compare the differentiation process and polarisation of these related cell populations and show that they exhibit different responses to chitosan (Ch), with human monocyte-derived macrophages polarising towards an anti-inflammatory phenotype while their DC counterparts display pro-inflammatory features. Macrophages and DC, whose interactions with biomaterials are frequently analysed using fully differentiated cells, were cultured directly on Ch films, rather than exposed to the polymer after complete differentiation. Ch was the sole stimulating factor and activated both macrophages and DC, without leading to significant T cell proliferation. After 10 d on Ch, macrophages significantly down-regulated expression of pro-inflammatory markers, CD86 and MHCII. Production of pro-inflammatory cytokines, particularly TNF-α, decreased with time for cells cultured on Ch, while anti-inflammatory IL-10 and TGF-ß1, significantly increased. Altogether, these results suggest an M2c polarisation. Also, macrophage matrix metalloproteinase activity was augmented and cell motility was stimulated by Ch. Conversely, DC significantly enhanced CD86 expression, reduced IL-10 secretion and increased TNF-α and IL-1ß levels. Our findings indicate that cells with a common precursor may display different responses, when challenged by the same biomaterial. Moreover, they help to further comprehend macrophage/DC interactions with Ch and the balance between pro- and anti-inflammatory signals associated with implant biomaterials. We propose that an overall pro-inflammatory reaction may hide the expression of anti-inflammatory cytokines, likely relevant for tissue repair/regeneration.

Analysis of the SLC4A1 gene in three Mexican patients with hereditary spherocytosis: Report of a novel mutation.

We analyzed the SLC4A1 gene in three Mexican patients with Hereditary Spherocytosis (HS). The promoter and all 20 exons were investigated through heteroduplex analysis and DNA sequencing. No DNA changes were detected in one of the three patients. Two well-known polymorphisms, Memphis I and the Diego-a blood group, were detected in another one. In the third, the HS phenotype could be explained by the novel 1885_1888dupCCGG mutation found in heterozygosis. This frameshift mutation is predicted to result in a truncated and unstable protein lacking normal functions.

Analysis of the SLC4A1 gene in three Mexican patients with hereditary spherocytosis: report of a novel mutation

We analyzed the SLC4A1 gene in three Mexican patients with Hereditary Spherocytosis (HS). The promoter and all 20 exons were investigated through heteroduplex analysis and DNA sequencing. No DNA changes were detected in one of the three patients. Two well-known polymorphisms, Memphis I and the Diego-a blood group, were detected in another one. In the third, the HS phenotype could be explained by the novel 1885_1888dupCCGG mutation found in heterozygosis. This frameshift mutation is predicted to result in a truncated and unstable protein lacking normal functions.

Sincronía ventricular en pacientes con bloqueo de rama del haz de his / Ventricular synchrony in patients with bundle branch block

Los trastornos de conducción representan un marcador de mál pronóstico en pacientes con cardiopatía. El objetivo fundamental fue evaluar la sincronía ventricular en pacientes con bloqueo de rama derecha del haz de His (BRDHH) y bloqueo de rama izquierda del haz de His (BRIHH). Estudio prospectivo, observacional, transversal, no experimental. Se evaluaron 45 pacientes: 25 con BRDHH y 20 con BRIHH e igual número de controles, que consultaron a la Emergencia de Adultos del Hospital "Dr. Alfredo Van Grieken", entre marzo y septiembre de 2008. Con ecocardiógrafo HP SONOS 5500 se determinó retardo intraventricular (RIV) según método de Pitzalis. Se observó RIV significativamente mayor en pacientes con BRIHH (x: 194,25 ± 73,33) que en BRDHH (x: 81,8 ± 39,23) y que en los controles (x: 21,96 ± 14,18), (P<0,01). La fracción de eyección (FE) fue menor en BRIHH (X: 35,05 ± 15,26) que en BRDHH (x: 57,28 ± 13,56) y que en controles (x: 63,49 ± 13,36), (P<=0,01). Se encontró correlación negativa significativa entre el RIV de BRIHH y la FE (r: 5,32, p: 0,05), la correlación entre la anchura del QRS y el RIV no fue significativa en BRDHH (r: 0,144), p: NS) ni en BRIHH (r: 0,160, p: NS). Se determinó asincronía intraventricular en 12% de los pacientes con BRDHH y en el 85% con BRIHH, 40% de este grupo falleció antes de culminar el estudio. La asincronía intraventricular en pacientes con BRIHH representa un riesgo de mortalidad cardiovascular elevado, lo cual nos obliga a implementar medidas profilácticas en la aparición de complicaciones y seleccionar a los pacientes para resincronización cardíaca.

Conduction disorders represent a marker of poor pronosis in patients with heart disease. The primary objective was to evaluate the ventricular synchrony in patients with right block (RBBB) and left bundle branch block (LBBB). Prospective, observational, cross-sectional, non experimental study. A total of 45 patients were evaluated: 25 with RBBB and 20 with LBBB and an equal number ofcontrols, that consulted the Adult Emergency Hospital "Dr. Alfredo Van Grieken", between march and septiember of 2008. Echocardiographic HP SONOS 5500 was used to determine intraventricular delay (IVD) by the Pitzalis method. IVD was significantly higher in patients with LBBB (x: 194.25 ± 73.33) thain in RBBB (x: 81.8 ± 39.23) and that in the controls (x: 21.96 ± 14.18), (P<0.01). The ejection fraction (EF) was lower in LBBB (x: 35.05 ± 15.26) than in RBBB (x: 57.28 ± 13.56) as well as control (x: 63.49 ±13.36). (P<0.01). Significant negative correlation was found between the IVD of LBBB and EF (r= 5.32, P: 0.05), the correlation betwen the width of the QRS and the IVD was not significant in RBBB (r: 0144, p: NS) nor in LBBB (r: 0160, p: NS). Intraventricular asynchrony was found in 12% of patients with RBBB. Death occurred in 40% of this group before completion of the study. Intraventricular asynchrony in patients with LBBB represents an elevated risk of cardiovascular mortality, which prophylactic measures to avoid complications and to select patients for cardiac resynchronization.

Influencia del origen etnico sobre la sensibilidad a insulina, perfil lipidico en personas entre 18 y 39 años / Influence of ethnic origen on insulin sensivity, lipid profile of persons with 18 and 39 years old

Se observa en ciertos grupos étnicos, un riesgo alto de desarrollar enfermedades crónicas no transmisibles (ECnT) cuando los sujetos son sometidos a dieta de alta densidad calórica y estilo de vida sedentaria. Este hecho se asocia al desarrollo de resistencia a insulina en estas mismas poblaciones. La resistencia a insulina está ligada a enfermedad cardiovascular posiblemente a través de cambios en el metabolismo de lípidos. El objetivo de este estudio fue evaluar la asociación entre el grupo étnico con sensibilidad a insulina, características bioquímicas y antropométricas.A 113 sujetos entre 18-39 años se les realizó encuesta de antecedentes familiares, antropometría, test de tolerancia a insulina, genotipificación ApoE y determinación de glucosa y lípidos. Los resultados fueron sometidos a Análisis de Regresión Múltiple para cada uno de los grupos étnicos. TAG se asocian significantemente con edad, sensibilidad a insulina e IMC en etnia blanca (p=0.016), mestiza (p=0.040) e indígena (p=0.040). Sin relación significante con colesterol total y col-HDL, etnia, IMC, edad y sensibilidad a insulina. Resistentes a insulina 44 por ciento, porcentaje relativamente alto considerando que es un grupo de personas jóvenes. La distribución del genotipo ApoE es: 2/ 3=7 por ciento, 3/3=72 por ciento, 3/4=17 por ciento y 4/4=2 por ciento con alto porcentaje del alelo E4. Los datos sugieren que la sensibilidad a insulina es independiente del grupo étnico, IMC y edad. El análisis estadístico permite concluir: que en la etnia blanca la concentración de TAG está correlacionada con la sensibilidad a insulina, en los mestizos se correlaciona con el IMC y en los indígenas con la edad y sensibilidad a insulina. En el grupo étnico negro ninguna de estas variables está correlacionada con los TAG. En cada etnia existen situaciones de riesgo para perfiles alterados de lípidos que se sabe están asociados al desarrollo temprano de ECNT. Los resultados de este estudio pueden ser utilizados como base para el diseño de estrategias de prevención para mejorar la calidad de vida en el adulto