Estrategias para la prevención de lesiones de ligamento cruzado anterior en mujeres deportistas con valgo dinámico de rodilla. Revisión sistemática / Strategies for the prevention of anterior cruciate ligament injuries in female athletes with dynamic knee valgus: Systematic review

Antecedentes y objetivo El aumento de la participación deportiva de las mujeres en la última década produce un aumento del riesgo, la frecuencia y la prevalencia de lesiones de ligamento cruzado anterior (LCA). Su incidencia de lesión es entre 2-8 veces mayor que en hombres debido a factores de riesgo como el valgo dinámico de rodilla (DKV). El objetivo de este trabajo consiste en evidenciar los programas de prevención actuales disponibles en la literatura científica, dirigidos a reducir las lesiones de LCA en mujeres deportistas con DKV y sus características en cuanto a variables y herramientas de medición, dosificación y aplicación. Material y métodos Se efectuó una revisión sistemática siguiendo la declaración PRISMA. Se buscó en las bases de datos PubMed, Cochrane, Embase, Science Direct, Web of Science y Scopus. Los artículos seleccionados tenían que mostrar las estrategias preventivas que pueden contribuir a reducir las lesiones del LCA en mujeres deportistas con DKV. Para valorar la calidad metodológica se utilizaron las escalas PEDro y STROBE. La última búsqueda fue realizada en febrero de 2022. Resultados Diecisiete estudios con un total de 1.634 participantes (79,5% mujeres; 20,5% hombres) cumplieron los criterios de inclusión de esta revisión. Todos los estudios mostraron mejoras significativas del DKV y del gesto deportivo. La fuerza y la activación muscular de miembros inferiores (59,3%) tras completar protocolos de control motor, fuerza o equilibrio también muestran mejoras significativas. Conclusiones Aunque sea necesaria una mayor investigación sobre la inclusión de estos programas en deportistas femeninas con DKV, los estudios revisados han comprobado que existen programas de prevención variados (pliometría, equilibrio, fuerza, entre otros) que aportan una mejora significativa del DKV y, por tanto, de la prevención de lesiones de LCA en mujeres deportistas a corto plazo (AU)

Background and objective The increase in female sports participation in the last decade has led to an increase in the risk, frequency and prevalence of anterior cruciate ligament (ACL) injuries. Their incidence of injury is 2–8 times higher than in men due to risk factors such as dynamic knee valgus (DKV). The aim of this study is to demonstrate the current prevention programmes available in the scientific literature aimed at reducing ACL injuries in female athletes with DKV and their characteristics in terms of variables and measurement tools, dosage and application. Material and methods A systematic review was conducted following the PRISMA statement. The databases PubMed, Cochrane, Embase, Science Direct, Web of Science and Scopus were searched. The articles selected had to show preventive strategies that can contribute to reducing ACL injuries in female athletes with DKV. The PEDro and STROBE scales were used to assess methodological quality. The last search was conducted in February 2022. Results Seventeen studies with a total of 1634 participants (79.5% women; 20.5% men) met the inclusion criteria for this review. All studies showed significant improvements in DKV and sport gesture. Lower limb muscle strength and activation (59.3%) after completing motor control, strength or balance protocols also showed significant improvements. Conclusions Although more research is needed on the inclusion of these programmes in female athletes with DKV, the studies reviewed have shown that there are varied prevention programmes (plyometrics, balance, strength, among others) that provide a significant improvement in DKV and, therefore, in the prevention of ACL injuries in female athletes in the short term (AU)

Recomendaciones para la rehabilitación respiratoria extrahospitalaria en pacientes con COVID persistente / Recommendations for outpatient respiratory rehabilitation of long COVID patients

La aparición de la COVID-19 ha supuesto un problema de salud pública mundial, provocando una elevada presión en los sistemas sanitarios. Las secuelas de esta enfermedad han puesto de manifiesto la importancia de la rehabilitación en pacientes COVID persistente, implicando en el proceso a diferentes profesionales. El tratamiento de las secuelas respiratorias en fase ambulatoria de esta reciente enfermedad es un campo especializado y parece oportuno ofrecer una serie de recomendaciones prácticas de rehabilitación cardio-respiratoria que ayuden a todos los profesionales implicados en la tarea de tratar este tipo de secuelas una vez superada la fase hospitalaria. Esta revisión de la literatura ofrece diez aspectos clave de fisioterapia respiratoria que incluyen la valoración, los parámetros que se deben monitorizar y los signos de alerta, así como las técnicas respiratorias específicas y otros ejercicios prácticos que se deben realizar en esta población.(AU)

The appearance of COVID-19 has been a problem for public health on a global scale, putting pressure on health care systems. The after-effects of this illness have highlighted the importance of rehabilitation in long COVID patients involving different health professionals. The treatment of the respiratory after-effects of this disease in an outpatient setting is a specialized field. It is appropriate to offer a series of practical recommendations of cardio-respiratory rehabilitation that are helpful to the professionals involved in the after-effects when ending hospitalisation. This review of the literature includes ten key aspects of respiratory physiotherapy that range from assessment, parameters to monitor, signs of alarm and respiratory rehabilitation techniques and other exercises for this population.(AU)

[Recommendations for outpatient respiratory rehabilitation of long COVID patients].

The appearance of COVID-19 has been a problem for public health on a global scale, putting pressure on health care systems. The after-effects of this illness have highlighted the importance of rehabilitation in long COVID patients involv-ing different health professionals. The treatment of the respiratory after-effects of this disease in an outpatient setting is a specialized field. It is appropriate to offer a series of practical recommendations of cardio-respiratory rehabilitation that are helpful to the professionals involved in the after-effects when ending hospitalisation. This review of the literature includes ten key aspects of respiratory physiotherapy that range from assessment, parameters to monitor, signs of alarm and respiratory rehabilitation techniques and other exercises for this population.

Improving the power performance of urine-fed microbial fuel cells using PEDOT-PSS modified anodes.

The need for improving the energy harvesting from Microbial Fuel Cells (MFCs) has boosted the design of new materials in order to increase the power performance of this technology and facilitate its practical application. According to this approach, in this work different poly(3,4-ethylenedioxythiophene)-polystyrenesulfonate (PEDOT-PSS) modified electrodes have been synthesised and evaluated as anodes in urine-fed MFCs. The electrochemical synthesis of PEDOT-PSS was performed by potentiostatic step experiments from aqueous solution at a fixed potential of 1.80 V (vs. a reversible hydrogen electrode) for different times: 30, 60, 120 and 240 s. Compared with other methods, this technique allowed us not only to reduce the processing time of the electrodes but also better control of the chemical composition of the deposited polymer and therefore, obtain more efficient polymer films. All modified anodes outperformed the maximum power output by MFCs working with the bare carbon veil electrode but the maximum value was observed when MFCs were working with the PEDOT-PSS based anode obtained after 30 s of electropolymerisation (535.1 µW). This value was 24.3% higher than using the bare carbon veil electrode. Moreover, the functionality of the PEDOT-PSS anodes was reported over 90 days working in continuous mode.

Fiabilidad interexaminador de la exploración de puntos gatillo miofasciales en la musculatura de las regiones cervical y lumbar / Inter-examiner reliability of the examination of trigger points in the cervical and lumbar spine regions

Objetivo: Conocer el grado de concordancia y la correlación interexaminadores al realizar la exploración manual de las características de banda tensa, banda sensible, dolor referido, dolor familiar, la respuesta de espasmo local y la algometría en los puntos gatillo explorados. Material y método: Estudio observacional prospectivo con 30 sujetos, 8 hombres (media: 36,55 años; desviación estándar:7,21) y 22 mujeres (44,53 años; desviación estándar: 0,81). Los examinadores fueron 2 fisioterapeutas noveles (N1 y N2) y un examinador experto (E1). Los músculos explorados: esternocleidomastoideo, trapecio superior, elevador de escápula, infraespinoso, cuadrado lumbar, glúteo medio y piramidal. Resultados: Kappa sustancial o casi perfecto entre examinadores para el lado dominante, excepto el dolor referido en el músculo piramidal con 0,35 (intervalo confianza -IC-95 por mil : 0 a 0,92) entre N1 frente a N2, 0,20(0 a 0,66) entre E1 frente a N2 y 0,27(0 a 0,77) entre E1 frente a N1 y la respuesta de espasmo local con 0,34(0 a 0,70) entre N1 frente a N2 para el músculo infraespinoso y 0(0,13 a 0,80) para el músculo trapecio superior. La correlación intraclase ha sido buena o muy buena para todos los músculos explorados, exceptuando el músculo elevador de escápula entre E1 frente a N1 con 0,68(0,44 a 0,83) y entre E1 frente a N2 con 0,69(0,45 a 0,84). Conclusiones: Obtenemos valor Kappa sustancial y/o casi perfecto entre examinadores, exceptuando en el dolor referido y la respuesta de espasmo local en algún músculo. Por otro lado, en el CCI para los valores de algometría, muestran una correlación buena o muy buena para todos los músculos a excepción del elevador de escápula

Objective: To determine the level of agreement and inter-rater reliability when performing the manual examination of the characteristics of taut band, sensitive edge, referred pain, familiar pain, local twitch response, and the algometry explored. Methods: A prospective observational study was conducted on 30 subjects including 8 men (mean: 36.55 years, standard deviation: 7.21) and 22 women (44.53 years old, standard deviation: 0.81). The examiners were 2 non-expert physiotherapists (N1 and N2) and an expert examiner (E1). Muscles explored: sternocleidomastoid, upper trapezius, levator scapula, infraspinatus, lumbar square, gluteus medius, and piriform. Results: Kappa was substantial or almost perfect between examiners for the dominant side, except pain referred to in the piriform muscle with 0.35 (confidence interval -95 per-mille CI: 0 - 0.92) between N1 vs. N2, 0.20 (0 - 0.66) between E1 vs. N2 and 0.27 (0 - 0.77) between E1 vs. N1 and local twitch response with 0.34 (0 - 0.70) between N1 vs. N2 for the infraspinatus muscle and 0 (0.13 - 0,80) for the upper trapezius muscle. Intraclass correlation was good or very good for all explored muscles, except for the levator scapula muscle between E1 vs. N1 with 0.68 (0.44 to 0.83) and between E1 vs. N2 with 0.69 (0.45 to 0.84). Conclusions: A substantial and/or almost perfect agreement (Kappa value) was obtained between examiners, except in the referred pain and local twitch response in some muscles. On the other hand, intraclass correlation for algometry values showed a good or very good correlation for all muscles except the levator scapula

Integración del proceso enfermero en la historia clínica electrónica de un hospital universitario / Integration of the nursing process in the electronic health record in an university hospital

Objetivo. Describir el proceso de implantación del Plan de Cuidados Individualizado Enfermero en la Historia Clínica Electrónica y su impacto en el Hospital Universitario Fundación Alcorcón. Metodología. Grupos de trabajo de enfermeras asistenciales que analizaron inicialmente las actividades enfermeras que realizaban habitualmente para crear el catálogo de diagnósticos, resultados e intervenciones. Se creó un grupo de referentes que depuró el catálogo para hacerlo manejable. Se diseñaron un plan de formación, los formularios de valoración enfermera y el Informe de Cuidados Enfermeros al alta. Resultados. En febrero de 2016 se implementó la nueva metodología en las unidades de hospitalización de adultos. Al 74,86-88,18% de los pacientes se les realizó un plan de cuidados con la nueva metodología. Entre un 69,41 y un 76,25% de los pacientes son dados de alta con un Informe de Cuidados Enfermeros conforme a la normativa. Se observó un aumento del 24,13% de los pacientes con Informe de Cuidados Enfermeros tras la implantación (p=0,000; RR 1,46; IC 95% 1,36-1,56). Se ha formado a un total de 116 enfermeras. Conclusiones. En las condiciones del estudio, la utilización de taxonomías enfermeras ha generado capacidad de reflexión y ha permitido emitir juicios enfermeros, aportar calidad de cuidados y aplicar intervenciones con unos resultados planificados. La taxonomía enfermera y el plan de cuidados en la historia clínica electrónica han permitido aumentar la comunicación interprofesional para mejorar la continuidad asistencial, a través de la mejora del Informe de Cuidados Enfermeros (AU)

Aim. To describe the process of implementation of Individualized Care Plan in the Electronic Health Record and its impact on the University Hospital Alcorcón Foundation. Methodology. Working groups of staff nurses who analyzed activities usually performed to create a catalog of diagnoses, outcomes and interventions. A group of referents that refined the catalog to make it manageable was created. A training plan, nursing assessment forms and the Nursing Discharge Report were designed. Results. In February 2016 the new methodology was implemented in inpatient units of adults. Between 74.86 and 88.18% of the patients underwent a care plan with the new methodology. Between 69.41 and 76.25% of patients are discharged with a Nursing Discharge Report accordance with regulations. An increase of 24.1% of patients with Nursing Discharge Report after implantation is observed (P=.000; RR: 1.46; 95% CI 1.36-1.56). A total of 116 nurses has been trained. Conclusions. In the study conditions, the use of nursing taxonomies has generated thinking skills and allowed nurses to issue judgments, ensure quality of care, and implementing interventions with a planned results. The nursing taxonomy and care plan in the Electronic Health Record have increased interprofessional communication to improve continuity of care through improved Nursing Discharge Report (AU)

[Integration of the nursing process in the electronic health record in an university hospital]. / Integración del proceso enfermero en la historia clínica electrónica de un hospital universitario.

AIM: To describe the process of implementation of Individualized Care Plan in the Electronic Health Record and its impact on the University Hospital Alcorcón Foundation. METHODOLOGY: Working groups of staff nurses who analyzed activities usually performed to create a catalog of diagnoses, outcomes and interventions. A group of referents that refined the catalog to make it manageable was created. A training plan, nursing assessment forms and the Nursing Discharge Report were designed. RESULTS: In February 2016 the new methodology was implemented in inpatient units of adults. Between 74.86 and 88.18% of the patients underwent a care plan with the new methodology. Between 69.41 and 76.25% of patients are discharged with a Nursing Discharge Report accordance with regulations. An increase of 24.1% of patients with Nursing Discharge Report after implantation is observed (P=.000; RR: 1.46; 95% CI 1.36-1.56). A total of 116 nurses has been trained. CONCLUSIONS: In the study conditions, the use of nursing taxonomies has generated thinking skills and allowed nurses to issue judgments, ensure quality of care, and implementing interventions with a planned results. The nursing taxonomy and care plan in the Electronic Health Record have increased interprofessional communication to improve continuity of care through improved Nursing Discharge Report.

Enhanced removal of 8-quinolinecarboxylic acid in an activated carbon cloth by electroadsorption in aqueous solution.

The effect of the electrochemical treatment (potentiostatic treatment in a filter-press electrochemical cell) on the adsorption capacity of an activated carbon cloth (ACC) was analyzed in relation with the removal of 8-quinolinecarboxylic acid pollutant from water. The adsorption capacity of an ACC is quantitatively improved in the presence of an electric field (electroadsorption process) reaching values of 96% in comparison to 55% in absence of applied potential. In addition, the cathodic treatment results in higher removal efficiencies than the anodic treatment. The enhanced adsorption capacity has been proved to be irreversible, since the removed compound remains adsorbed after switching the applied potential. The kinetics of the adsorption processes is also improved by the presence of an applied potential.

Fiabilidad de los test de diagnóstico de disfunción sacroilíaca y de las pruebas exploratorias de la pelvis / Reliability of diagnostic tests of sacroiliac joint dysfunction and of the pelvic examination studies

Objetivos: El propósito de este estudio fue determinar el grado de fiabilidad interexaminadores e intertest de las pruebas de diagnóstico de disfunción sacroilíaca y de los signos exploratorios de la pelvis. Material y métodos: Dos examinadores exploraron por separado la articulación sacroilíaca en 30 sujetos universitarios (10 hombres; 20 mujeres; edad media ± desviación estándar 24,56 ± 5,2). Se realizaron 4 test de diagnóstico de disfunción sacroilíaca: test de flexión en bipedestación (TFB), test de flexión en sedestación (TFS), test de Gillet para ilíaco (TGI) y test de Gillet para sacro (TGS). Posteriormente, se completó la valoración con la exploración visual y palpatoria de la asimetría pélvica y de la dismetría de miembros inferiores. Resultados: Los índices de Kappa interexaminadores obtenidos para los test realizados -TFB, TFS, TGI, TGS- fueron de -0,082; -0,064; 0,262, y 0,170, respectivamente, y de -0,005 y -0,220 para la asimetría pélvica y para la dismetría de miembros inferiores. Para valorar la fiabilidad intertest, se emparejaron aquellas pruebas destinadas a la evaluación de la misma variable de disfunción sacroilíaca. Para el binomio TFB-TGI se obtuvieron valores de Kappa en cada examinador de -0,049 y 0,099, y en el caso de TFS-TGS, valores de 0,017 y 0,116. Conclusiones: Los resultados obtenidos muestran que no existe fiabilidad significativa entre examinadores en la exploración sacroilíaca y pélvica, así como tampoco entre los test destinados a evaluar el mismo tipo de variable de disfunción sacroilíaca

Objectives: The purpose of this study was to determine the degree of inter-examiner and inter-test reliability in the diagnostic tests of sacroiliac dysfunction and in the signs of pelvic exploration. Material and methods: Two examiners separately examined the sacroiliac joint in 30 university subjects (10 men, 20 women, mean age = 24.56, SD = 5.2). Four diagnostic sacroiliac dysfunction tests were performed: standing flexion test (StFT), sitting flexion test (SiFT) and Iliac Gillet test (IGT) and Sacral Gillet test (SGT). Assessment was completed with a visual examination and palpation of pelvic asymmetry and lower limb dysmetria. Results: The Kappa inter-examiner rates obtained for StFT was -0.082, for the SiFT was -0.064, for the IGT was 0.262, for the SGT was 0.170, for pelvic asymmetry was -0.005, and for lower limb dysmetria was -0.220. The tests aimed at the evaluation of the same variable of sacroiliac dysfunction were matched to evaluate the inter-test reliability. For the binomial StFT-IGT, Kappa values were obtained for each examiner of -0.049 and 0.099, and for the binomial SiFT-SGT, values of 0.017 and 0.116 were obtained. Conclusions: The results show that there is no significant reliability between examiners in the sacroiliac and pelvic examination and between the tests that evaluate the same variable of sacroiliac joint dysfunction

Removal of 8-quinolinecarboxylic acid pesticide from aqueous solution by adsorption on activated montmorillonites.

Sodium montmorillonite (Na-M), acidic montmorillonite (H-M), and organo-acidic montmorillonite (Org-H-M) were applied to remove the herbicide 8-quinolinecarboxylic acid (8-QCA). The montmorillonites containing adsorbed 8-QCA were investigated by transmission electron microscopy, FT-IR spectroscopy, X-ray diffraction analysis, X-ray fluorescence thermogravimetric analysis, and physical adsorption of gases. Experiments showed that the amount of adsorbed 8-QCA increased at lower pH, reaching a maximum at pH 2. The adsorption kinetics was found to follow the pseudo-second-order kinetic model. The Langmuir model provided the best correlation of experimental data for adsorption equilibria. The adsorption of 8-QCA decreased in the order Org-H-M > H-M > Na-M. Isotherms were also used to obtain the thermodynamic parameters. The negative values of ΔG indicated the spontaneous nature of the adsorption process.

Monitorización del flujo sanguíneo regional cerebral mediante la flujometría por difusión termal. Descripción de 3 casos / No disponible

El flujo sanguíneo cerebral es el parámetro más importante en el pronóstico de la lesión cerebral. Una medida regional del flujo se puede obtener usando métodos continuos como la flujometría por difusión termal, que permite detectar y cuantificar fenómenos isquémicos relacionados con el clipaje temporal arterial o malposición del clip definitivo y en pacientes que han sufrido una hemorragia subaracnoidea o un traumatismo craneoencefálico. Asimismo, la detección precoz de la isquemia podría ayudarnos a adoptar más rápidamente medidas terapéuticas y con mayor eficacia. Presentamos 2 casos durante cirugía de clipaje de aneurisma y un caso en cuidados intensivos donde valoramos: el efecto de diferentes hipnóticos sobre la flujometría por difusión termal; la relación entre esta y los potenciales evocados somatosensoriales y motores; y cambios en la flujomería y Doppler transcraneal durante el vasoespasmo. La flujometría por difusión termal mostró variaciones en tiempo real del flujo sanguíneo producidas por anestésicos endovenosos e inhalatorios. Detectó cambios del flujo sanguíneo cerebral antes que los potenciales evocados y el Doppler(AU)

No disponible

[Regional cerebral blood flow monitoring using thermal diffusion flowmetry. Description of 3 cases]. / Monitorización del flujo sanguíneo regional cerebral mediante la flujometría por difusión termal. Descripción de 3 casos.

Cerebral blood flow is the most important physiologic parameter in the setting of brain injury. A regional measurement of the flow (rCBF), can be obtained using continuous methods such as thermal diffusion flowmetry (TD-rCBF). This technology of monitoring allows us to detect and quantify ischemic events related with the temporary artery clipping or malposition of the definitive clip and in patients who have suffered a subarachnoid hemorrhage (SAH) or a traumatic brain injury. Likewise, the precocious detection of ischemic events might help us to adopt more rapidly therapeutic measures and more efficienty. Three cases show during aneurysm clipping procedures and at intensive care: the effects of different hypnotics on TD-rCBF values; the relationship between TD-rCBF and somatosensory and motor evoked potentials; and changes in TD-rCBF and transcranial Doppler ultrasonography (TDU) during a vasospasm. TD-rCBF showed in real-time flow variations induced by anaesthetics and detected changes of CBF earlier than evoked potentials and TDU.

Preparation and characterization of copper-doped cobalt oxide electrodes.

Cobalt oxide (Co3O4) and copper-doped cobalt oxide (CuxCo(3-x)O4) films have been prepared onto titanium support by the thermal decomposition method. The electrodes have been characterized by different techniques such as cyclic voltammetry, scanning electron microscopy, X-ray diffraction, and X-ray photoelectron spectroscopy (XPS). The effect on the electrochemical and crystallographic properties and surface morphology of the amount of copper in the oxide layer has been analyzed. The XPS spectra correspond to a characteristic monophasic Cu-Co spinel oxides when x is below 1. However, when the copper content exceeds that for the stoichiometric CuCo2O4 spinel, a new CuO phase segregates at the surface. The analysis of the surface cation distribution indicates that Cu(II) has preference for octahedral sites.

[Systemic mastocytosis: clinical case]. / Mastocitosis sistémica: caso clínico.

We report a 38 years old female who, since her childhood, had a history of precisely limited, fixed maculo papular dark brown cutaneous lesions in the trunk and extremities. These lesions become erythematous or urticarial after rubbing, medication intake or scratching. She also had frequent episodes of tachycardia, flushing, headache, abdominal pain, arthralgia, diarrhea and vomiting. She was hospitalized in three occasions due to high frequency tachycardia, hypotension, generalized urticarial erythema and clouding of consciousness. Three of these episodes occurred after the ingestion of antiinflammatory drugs or acetylsalicylic acid. Mastocyte infiltration was confirmed in skin and bone marrow biopsies and in bone scintiscan. The use of H1, H2 blockers and mastocyte stabilizers gave partial relief to the patient.

[Alternative treatment for acute asthmatic crisis]. / Alternativa de tratamiento de la crisis aguda de asma.

In a double blind study, 20 patients who presented with acute episodes of asthma were randomized to treatment with nebulized salbutamol (5 mg) of subcutaneous salbutamol (0.5 mg). The clinical conditions were not significantly different before or after treatment in both groups. Significant bronchial dilation was obtained to a similar level in both groups. The heart rate increased significantly in the group treated by subcutaneous injection. Other side effects were minor and similar in both groups. Thus nebulized salbutamol may be used to treat acute asthma in selected patients.

Evolución antropológica de la sexualidad una introducción sucinta / Anthropologic evolution of human sexuality

La evolución de la función sexual es analizada, en forma breve, desde su comienzo biologico hace millones de años hasta la fecha, subrayando las facetas antropológicas. Se reume el cambio de los roles sexuales, en el marco de diferentes etapas evolutivas de la organización social, señalando diversos comportamientos y valores. Se discute el significado social de los dos últimos, aportando algunas guías para su interpretación

Hipertension arterial en el medio rural. / Arterial hypertension in a rural area

Los autores analizan la prevalencia, la distribucion por sexo y grupos de edad y algunas caracteristicas clinicas de la hipertension en los adultos atendidos en el Consultorio de Quintero. Destacan una prevalencia de 4,3% el predominio de las mujeres (74%) sobre los hombres (26%) el hallazgo de un 15% de casos severos con presiones diastolicas superiores a 115 mm de Hg; la concomitancia de diabetes en el 10% de los pacientes. Hacen hincapie en la necesidad de un programa que establezca normas de estudio, de tratamiento y de control de los pacientes a traves del tiempo y que se complemente con la educacion sanitaria del enfermo y de su grupo familiar. De no cumplirse estos requisitos los esfuerzos aislados son infructuosos y no modifican la evolucion natural de la hipertension, la frecuencia de sus complicaciones ni la sobrevida de los pacientes