Uso de medicamentos en la población adulta mayor de 60 años que viven en comunidad en Bogotá, Colombia

24 

(1)PONTIFICIA UNIVERSIDAD JAVERIANA FACULTAD DE MEDICINA ESPECIALIZACIÓN EN GERIATRÍA. USO DE MEDICAMENTOS EN LA POBLACIÓN ADULTA MAYOR DE 60 AÑOS QUE VIVEN EN COMUNIDAD EN BOGOTA, COLOMBIA. JAVIER CABRERA TRABAJO DE GRADO PRESENTADO COMO REQUISITO PARCIAL PARA OPTAR AL TÍTULO DE MÉDICO GERIATRA. ESPECIALIZACIÓN EN GERIATRÍA BOGOTÁ, DC NOVIEMBRE, 2014.

(2) NOTA DE ADVERTENCIA "La Universidad no se hace responsable por los conceptos emitidos por sus alumnos en sus trabajos de tesis. Solo velará por que no se publique nada contrario al dogma y a la moral católica y por que las tesis no contengan ataques personales contra persona alguna, antes bien se vea en ellas el anhelo de buscar la verdad y la justicia". Artículo 23 de la Resolución No13 de julio de 1946..

(3) USO DE MEDICAMENTOS EN LA POBLACIÓN ADULTA MAYOR DE 60 AÑOS QUE VIVEN EN COMUNIDAD EN BOGOTA, COLOMBIA. APROBADO: _____________________________ CARLOS ALBERTO CANO Director del postgrado Geriatría. Jurado 1 _____________________________ RODRIGO ALBERTO HEREDIA Médico Geriatra. Jurado 2 _____________________________ DIEGO ANDRES CHAVARRO CARVAJAL Médico Geriatra. AUTOR: JAVIER CABRERA.

(4) USO DE MEDICAMENTOS EN LA POBLACIÓN ADULTA MAYOR DE 60 AÑOS QUE VIVEN EN COMUNIDAD EN BOGOTA, COLOMBIA. JAVIER CABRERA. __________________________________ MERY BERMUDEZ Decana Académica de la facultad de Medicina. __________________________________ JUAN GUILLERMO CATAÑO Directo de Postgrados de la facultad de Medicina.

(5) Abstract. Background: Most studies on medication use in the elderly concentrate on nursing home or hospitalized population. SABE (Survey on Health, Well-Being, and Aging) is a population-based study which has collected data on several Latin American and Caribbean major cities. To the Bogota survey we added a section on medication use. Objective: To determine how many drugs, what types of medications are routinely used by a sample of elderly in the Colombian capital, and how many of those would be classified as potentially inappropriate. Methods: This door-to-door survey was answered by a population-based sample of people age 60 and over after a multi-stage cluster house sampling methodology. Questions of interest included sociodemographic variables, cognitive status, health status, functional evaluation and medication use. Results: 1249 female and 751 male subjects age 60 or over answered the questionnaire, 1514 of them (75.7%) have 5 years of school or less. Selfreported prevalence of hypertension was 60.0% and 56.5% for females and males, respectively; the figure for diabetes was 22.7% and 10.0%. 311 subjects (15.6%) were not taking any medication (range 0-14; median 3). The average number of medications (overall 3.24) was higher in women (3.50) than in men (2.79). 548 subjects (27.4%) were receiving 5 medications or more. Of the 6470 medications being used, 443 (6.9%) were potentially inappropriate according to the Beers criteria.

(6) Conclusion:. Despite. the. frequency. of. polypharmacy. and. potentially. inappropriate medication use, our figures are lower than previously published hospital-based studies from Latin America, or community dwelling elderly in developed countries.. Key points (2-3): Polypharmacy in community-dwelling elderly is lower in Bogota than in developed countries or in local or regional hospital-based samples. On average, women take more medications than men..

(7) Introduction. With a rapidly growing aging population, the problem of polypharmacy in the elderly is becoming an increasing concern for healthcare systems and for the general population. Most studies on appropriate use of medications, and on strategies to prevent and manage polypharmacy, come from developed countries. (1) However, polypharmacy is increasingly recognized as a serious health concern in developing countries where less control on prescription and delivery of medications is a big concern. In Latin America, most studies come from Brazil(2, 3) and Mexico(4). There is only one study, based on a single hospital, on medication use in elderly population in Colombia.(5). This manuscript uses data from a population-based study that followed the methodology of an older multinational population-based study carried out in 7 main cities in Latin America (Bridgetown, Buenos Aires, Havana, Mexico City, Montevideo, Santiago, and Sao Paulo) called the SABE Study. The original SABE study was designed to determine living standards and health-related conditions of representative samples of elderly population.(6) In 2012, we used a modified and updated instrument to 2000 older adults in the capital city of Colombia: Bogota. This manuscript describes medication use among the elderly in Bogotá. It also uses the Beers criteria for inappropriate medication in the elderly, which have been updated recently, to evaluate medication use among older adults in Bogotá.(7).

(8) Methods. The SABE (for the words in Spanish meaning Survey on Health, Well-Being, and Aging) was designed by the Pan American Health Organization and several academic centers in the United States and was conducted in the seven capital cities in Latin America. Ecuador and Colombia have recently joined the group.. Survey topics: The survey includes 11 main topics: 1) identification of the place of residence and of the elderly people to be interviewed; 2) housing characteristics; 3) personal and family data; 4) lifetime experiences with violence; 5) cognitive status; 6) health status; 7) characterization and causes of disabilities; 8) functional evaluation; 9) medication use and health services access; 10) anthropometric and execution assessment; 11) health, disease and a social history framework (biological component). This manuscript focuses on medication use.. Sampling methodology: This was a cross-sectional study, carried out in 2012, in both urban and rural areas of the city of Bogota. The sample was collected by multi-stage clusters (sectors, sub-sections of neighborhoods, blocks, and groups of 10 houses), and designed to obtain a representative sample by weighting main sociodemographic variables in the cluster selection. Original sample size calculations estimated an initial population size of 1685 subjects; assuming a rejection rate of 45% (based on previous SABE study reports, where rejection rate was 40%) the corrected sample increased to 2444 identified subjects. Of this group, 2000 adults agreed to participate and were.

(9) interviewed (acceptance rate of 81.4%). A team of one supervisor, 3-4 interviewers, and a professional in charge of anthropometric measurements performed the door-to-door survey, taking around 2 hours per subject interviewed.. Statistical analysis: Survey results were collected in paper, results were transferred into an Excel database independently by two coders. For the descriptive analysis, we estimated means, standard errors and percentages. For gender differences in each age group in number of medications taken, we used the U Mann Whitney test. Correlation between age and number of medications taken was evaluated using the Spearman Rank Correlation test.. Ethical aspects: All participants or their caregivers signed an informed consent. The study complied with national Colombian ethical standards (Resolution 8430 of 1993), and was approved by Pontificia Universidad Javeriana’s medical school ethics committee.. Results. A total of 2000 subjects age 60 or more answered the SABE Bogota questionnaire. Table 1 shows the general characteristics of our sample. Very old adults (those older than 80 years of age) account for 17% of the total sample. Additionally, more than 70% of respondents have 5 years of education or less. Table 2 shows the most common self-reported medical conditions. Hypertension, arthritis and osteoporosis are the most prevalent conditions.

(10) among both men and women with higher prevalence rates observed among women in the three conditions.. Tables 1 and 2 around here. Self-reported health, was evaluated and 122 (6.1%) respondents rated their health as “excellent”, 823 (41.1%) as “very good”, 911 (45.6%) as “fair”, and 144 (7.2%) as poor. Cognition was also evaluated with a modeified version of the mini-mental state examination (MMSE). A total of 252 respondents (12.6%) had a score below 13/19, and 514 (25.7%) had a of 6 or more in the Geraitric Depression Scale, also known as the Yesavage Scale.. Table 3 shows the number of different medications received by the patients in our sample. It is interesting to note that of the 1173 subjects deemed to have hypertension, 1065 (90.8%) were taking medication, while 720 (61.4%) were following a diet. In addition, among the 358 participants with diabetes, 93 where receiving insulin.. Table 3 about here. Table 4 shows the active ingredients most commonly used among the 2000 respondents. We further group these medications in Table 5 by drug category. The 2000 subjects received a total of 6470 different medications, for an average of 3.24 medications per person. Most medications (5933, 91.7%) had been prescribed by a physician, 174 (2.7%) by a relative and 140 (2.2%) were self-.

(11) prescribed. Of our total sample, 1689 subjects (84.4%) were receiving at least on medication while 548 (27.4%) were receiving 5 medications or more.. Tables 4 and 5 about here. After analyzing the descriptive tables we used the updated Beers criteria to identify potentially inappropriate medication use in our sample of older adults.(8) we found a total of 33 potentially inappropriate medications being used in our sample. Table 6 presents a list of the 20 most frequently being used. Of the 6470 medications being used, 443 (6.9%) fulfill the Beers criteria and are potentially innapropriate for the studied group.. Table 6 about here. We finally decided to explore the relationship between number of medications used, gender and age. Table 7 shows the association between gender, age and the number of medications received. A weak statistically significant correlation between age and number of medications taken is observed in the table for both men an women. This association is not significant for the oldest old. Table 7 about here. Discussion The reduction in polypharmacy and avoidance of inappropriate medications is, for several reasons, a common goal in the care of older persons, regardless of.

(12) setting.(9) Polypharmacy has been defined as the use of multiple medications or the use of medications with similar pharmacological profile that cause increased risk for drug-drug and drug-disease interactions.(9) One of the most commonly used definitions is the concurrent use of 5 or more drugs,(10, 11) a definition that has been used in other Latin American studies.(3, 12) Even though there are individuals who require more than five medications to control multiple medical conditions, polypharmacy is harmful for different reasons.(13) First, drug-drug interactions become a very important issue.(14) Second, studies have shown that the larger the number of medications used, the smaller the adherence to medical treatments.(15, 16) Finally, quality of life for patients decreases significantly as the number of medications increases.(16). The rise in polypharmacy is driven by the growth of an aging population and by the increasing prevalence of multi-morbidity. Polypharmacy has been associated with multiple diseases, advanced age, being female, low level of self-rated health, lower income, low educational attainment, living in an institution, and number of visits to a primary care provider per year.(11) Patients’ knowledge about their treatment and their health and expectations may play a role.(15) Patients with high education may have greater access to drug information and may therefore be more active in patient-physician communication and influence prescription of a new drug.(11) The low educational level of our sample would agree with this finding.. Overall, frequency of polypharmacy in our study is lower than other studies have reported, even in community dwelling elderly. Gnjidic et al., in Australia,.

(13) found an average of 4.0 medications per individual in their sample of 1,705 elderly age 70 or more.(10) The Sao Paulo SABE study found 36% of their elderly with 5 or more medications, compared with our 27%, and their elderly were taking an average of 3.6 medications per individual, compared with our 3.2. (3) They also found a higher rate in females than males, a fact that has been described in other studies.(11, 17) Rates of polypharmacy are even higher in hospital-based studies: Marzi et al. found 6.1 medications per individual in their population of 179 elderly in an Argentinian hospital.(18) Their rate of potentially inappropriate medications according to Beers Criteria was also higher: of the 1086 prescriptions, 179 (16.5%) were identified as potentially inappropriate. Figures from a community based study in Taiwan (19.1% using 2003 Beers criteria are also higher than ours (6.9%).(17) Comparisons of polypharmacy, therefore, need to consider the setting of the study: communitybased studies show lower figures than nursing homes(19, 20) and hospitalbased studies(18) since this can potentially bias the results obtained.. Despite these differences in prevalence that could be derived from a variety of sources including the way the data was collected, the type of population analyzed and recall bias depending on the type of study, there are groups of medications that have been shown to affect older adults and that should be avoided or used with extreme care in this population group. For example, it is well established that sedative-hypnotic drugs (e.g., benzodiazepines) increase the risk of falls (17) and cognitive decline(19). It has also been shown that there is a greater risk of adverse drug events (e.g., gastrointestinal hemorrhage) iamong older patients taking nonsteroidal anti-inflammatory drugs.(21) In our.

(14) study however, these medications were among the most commonly prescribed in our sample of adults over 60 years of age.. Conclusion Polypharmacy is an important issue affecting community dwelling older adults around the world. Advances in medical knowledge and technology have prolonged life and this has resulted in many individuals living longer with chronic conditions and requiring medications for longer periods of time increasing the risk for potentially inappropriate use of medications. Our data shows prevalence rates of polypharmacy among adults over 60 years of age that are a concern form the pubic health perspective. These results need to inform policy makers and health-care providers on the importance of identifying medications that are potentially harmful for older adults and constantly reviewing prescription practices in this population group to avoid life-threatening events and improve overall care of this rapidly growing population group.. Acknoledgements The SABE Bogotá study was supported by a grant number 120354531692 of the Administrative Department of Science, Technology and Innovation in Colombia (COLCIENCIAS) and by the Pontificia Universidad Javeriana. The authors declare no conflicts of interest..

(15) References 1. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345-51. 2. Baldoni Ade O, Ayres LR, Martinez EZ, Dewulf Nde L, Dos Santos V, Pereira LR. Factors associated with potentially inappropriate medications use by the elderly according to Beers criteria 2003 and 2012. International journal of clinical pharmacy. 2014;36(2):316-24. 3. Carvalho MF, Romano-Lieber NS, Bergsten-Mendes G, Secoli SR, Ribeiro E, Lebrao ML, et al. Polypharmacy among the elderly in the city of Sao Paulo, Brazil - SABE Study. Revista brasileira de epidemiologia = Brazilian journal of epidemiology. 2012;15(4):817-27. 4. Sanchez-Gutierrez R, Flores-Garcia A, Aguilar-Garcia P, Ruiz-Bernes S, Sanchez-Beltran CA, Benitez-Guerrero V, et al. [Effects of Polypharmacy of Older Adult Quality of Life]. Revista Fuente. 2012;10:70-5. 5. Holguin E, Orozco JG. Medicación potencialmente inapropiada en ancianos en un hospital de cuarto nivel en Bogotá. Universitas Médica. 2011;52(2). 6. Menendez J, Guevara A, Arcia N, Leon Diaz EM, Marin C, Alfonso JC. [Chronic diseases and functional limitation in older adults: a comparative study in seven cities of Latin America and the Caribbean]. Rev Panam Salud Publica. 2005;17(5-6):353-61. 7. American Geriatrics Society Beers Criteria Update Expert P. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2012;60(4):616-31. 8. Resnick B, Pacala JT. 2012 Beers Criteria. Journal of the American Geriatrics Society. 2012;60(4):612-3. 9. Gokula M, Holmes HM. Tools to reduce polypharmacy. Clinics in geriatric medicine. 2012;28(2):323-41. 10. Gnjidic D, Hilmer SN, Blyth FM, Naganathan V, Waite L, Seibel MJ, et al. Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. Journal of clinical epidemiology. 2012;65(9):989-95. 11. Haider SI, Johnell K, Weitoft GR, Thorslund M, Fastbom J. The influence of educational level on polypharmacy and inappropriate drug use: a registerbased study of more than 600,000 older people. Journal of the American Geriatrics Society. 2009;57(1):62-9. 12. Rojas M, Ruiz I, Carrasco VH, Molina JC. Caracterización de pacientes y de uso de medicamentos en un grupo de adultos mayores asistentes a una actividad promocional de geriatría. Rev Hosp Clín Univ Chile. 2008(19):318-23. 13. Wise J. Polypharmacy: a necessary evil. Bmj. 2013;347:f7033. 14. Secoli SR, Figueras A, Lebrao ML, de Lima FD, Santos JL. Risk of potential drug-drug interactions among Brazilian elderly: a population-based, cross-sectional study. Drugs & aging. 2010;27(9):759-70. 15. Horne R, Weinman J. Patients' beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. Journal of Psychosomatic Research. 1999;47(6):555-67..

(16) 16. Vik SA, Maxwell CJ, Hogan DB. Measurement, correlates, and health outcomes of medication adherence among seniors. Annals of Pharmacotherapy. 2004;38(2):303-12. 17. Lai SW, Liao KF, Liao CC, Muo CH, Liu CS, Sung FC. Polypharmacy correlates with increased risk for hip fracture in the elderly: a population-based study. Medicine (Baltimore). 2010;89(5):295-9. 18. Marzi MM, Diruscio AV, Nunez HM, Pires SM, Quaglia BN. [Analysis of medication prescription in an Argentinian geriatric hospital]. Rev Med Chil. 2013;141(2):194-201. 19. Bosboom PR, Alfonso H, Almeida OP, Beer C. Use of Potentially Harmful Medications and Health-Related Quality of Life among People with Dementia Living in Residential Aged Care Facilities. Dement Geriatr Cogn Dis Extra. 2012;2(1):361-71. 20. Ruggiero C, Dell'Aquila G, Gasperini B, Onder G, Lattanzio F, Volpato S, et al. Potentially inappropriate drug prescriptions and risk of hospitalization among older, Italian, nursing home residents: the ULISSE project. Drugs & aging. 2010;27(9):747-58. 21. Gallagher PF, O'Connor MN, O'Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clinical pharmacology and therapeutics. 2011;89(6):845-54..

(17) Table 1. General characteristics of our sample (n=2000) Variable. Mean (SD) or n (%). Age(years). 71.2 (8.1). 60-69. 960 (48.0%). 70-79. 702 (35.0%). 80-89. 301 (15.1%). > 90. 37 (1.9%). Gender (%) Female. 1249 (62.5%). Male. 751 (37.5%). Education (years) None. 235 (11.7%). 1-5. 1279 (64.0%). 6-11. 483 (24.1%). 12 or more. 3 (0.2%).

(18) Table 2. Self-reported medical conditions (n=2000) Medical conditions. Male. Female. n(%). n(%). Hypertension. 424 (56.5%). 749 (60.0%). Arthritis. 140 (18.6%). 493 (39.5%). Osteoporosis. 94 (12.5%). 299 (23.9%). Diabetes. 75 (10.0%). 283 (22.7%). COPD1. 61 (8.1%). 273 (21.9%). Cancer. 46 (6.1%). 85 (6.8%). Congestive Heart Failure. 17 (2.2%). 112 (9.0%). Psychiatric conditions. 27 (3.6%). 79 (6.3%). 1. Chronic Obstructive Pulmonary Disease.

(19) Table 3. Number of medications used by the subjects in our sample (n=2000) Number of medication. n (%). 0. 311 (15.6%). 1. 268 (13.4%). 2. 314 (15.7%). 3. 296 (14.8%). 4. 263 (13.2%). 5. 199 (10.0%). 6. 142 (7.1%). 7. 70 (3.5%). 8. 49 (2.5%). 9. 38 (1.9%). 10. 25 (1.3%). 11. 7 (0.4%). 12. 10 (0.5%). 13. 2 (0.1%). 14. 4 (0.2%). 15. 0 (0%). 16. 2 (0.1%). Total. 2000 (100%).

(20) Table 4. Active ingredients most commonly used by the subjects in our sample. Percentage is based on the 1689 subjects that reported using at least 1 medication. Active Ingredient. n (%). 1. Aspirin. 594 (35.2%). 2. Losartan. 495 (29.3 %). 3. Omeprazole. 399 (23.6%). 4. Acetaminophen. 372 (22.0%). 5. Enalapril. 331 (19.6%). 6. Levothyroxine. 278 (16.5%). 7. Hydrochlorothiazide. 272 (16.1%). 8. Lovastatin. 257 (12.9%). 9. Calcium. 209 (15.2%). 10. Metoprolol. 184 (10.9%). 11. Metformin. 158 (9.4%). 12. Amlodipine. 134 (7.9%). 13. Fatty acids omega-3. 117 (6.9%). 14. Verapamil. 106 (6.3%). 15. Furosemide. 101 (6.0%). 16. Medicinal plants. 88 (5.2%). 17. Atorvastatin. 73 (4.3%). 18. Insulin. 73 (4.3%). 19. Glucosamine. 72 (4.2%). 20. Salbutamol. 64 (3.8%).

(21) Table 5. Medications grouped by drug category. Percentage is based on the 1689 subjects that reported using at least 1 medication. Drug category. Number of participants using the category n(%). Antihypertensives. 1479 (87.6). Antiplatelet agents. 615 (36.4). Proton pump inhibitors. 417 (24.7). Diuretics. 415 (24.6). Statins. 337 (20.0). Hypoglycemic agents. 298 (17.6). Thyroid hormone. 278 (16.5). Vitamins. 198 (11.7). Non-steroidal anti-inflammatory. 161 (9.5). agents Antidepressants. 76 (4.5). Antihistamines. 74 (4.4). Antibiotics. 55 (3.3). Anticoagulant agents. 30 (1.8). Antipsychotic agents. 19 (1.1).

(22) Table 6. Self-reported potentially inappropriate medication use according to Beers criteria. Percentage is based on the 1689 subjects that reported using at least 1 medication. Active ingredient. n (%). 1. Diclofenac. 50 (3%). 2. Naproxen. 50 (3%). 3. Nifedipine. 47 (2.8%). 4. Ibuprofen. 47 (2.8%). 5. Spironolactone. 39 (2.3%). 6. Prazosin. 26 (1.5%). 7. Clonidine. 18 (1.1%). 8. Methocarbamol. 15 (<1%). 9. Haloperidol. 12 (<1%). 10. Clonazepam. 11 (<1%). 11. Chlorpheniramine. 8 (<1%). 12. Hyoscyamine. 7 (<1%). 13. Amitriptyline. 7 (<1%). 14. Amiodarone. 6 (<1%). 15. Metoclopramide. 6 (<1%). 16. Imipramine. 5 (<1%). 17. Piroxicam. 5 (<1%). 18. Digoxin. 4 (<1%). 19. Quetiapine. 4 (<1%). 20. Meloxicam. 4 (<1%).

(23)

(24) Table 7. Number of medications taken by age group and gender; p value was estimated using U Mann-Whitney test for median analyses Age. Males n. Females Mean. p-. Median. n. Mean. Median. value. (SD) 60 - 64. 185. 2.1 (2.35). 1. 321. 2.93 (2.45). 3. <0.001. 65 - 69. 164. 2.35. 2. 290. 3.14 (2.56). 3. <0.01. 3. 247. 3.81 (2.50). 4. <0.01. 3. 180. 3.91 (2.75). 4. <0.05. 3. 123. 4.46 (2.71). 4. <0.01. 2. 62. 3.87 (2.65). 3.5. >0.5. 4. 26. 3.50 (2.47). 4. >0.5. 2. 124. 3.50 (2.61). 3. <0.001. (2.06) 70 - 74. 151. 3.05 (2.46). 75 - 79. 124. 3.34 (2.74). 80 - 84. 83. 3.43 (3.03). 85 - 89. 33. 3.33 (2.82). 90 and. 11. more Total. 4.82 (3.28). 751. 2.79 (2.56). 9.

(25)

Nuevo documento

El estudio realizado permite concluir que la reducción del consumo de cigarrillos ratifica la importancia del precio en los programas de prevención y control del tabaquismo; que el

intervengamos enfermos por operaciones innecesarias o lo hagamos tan tardíamente que las secuelas se hayan establecido; cuando abandonemos las guardias irresponsablemente y la dejamos

En Cuba, la Escuela Nacional de Salud Pública ha promovido investigaciones e ideas en relación con la intersectorialidad y emitido sus criterios, muchos de los cuales comparten los

Su contenido está referido a la movilización comunitaria y coordinación intersectorial, formar recursos humanos en epidemiología y toxicología ambientales, fortalecer las funciones de

En el campo de la aplicación de las buenas prácticas en general, y su extensión a los aspectos relacionados con la investigación clínica, resulta en ocasiones algo difícil comprender su

Conjugar los modelos de medicina personalizada, medicina genómica y medicina social es un resultado posible en el sistema cubano de salud, cuya expresión puede medirse en términos de

Esta hipótesis, también denominada como del "Feto Ahorrador o Aprovechador" provee la razón para creer que al menos por una o dos generaciones, la diabetes y otras ENTs en esta parte

Palabras clave: industria farmacéutica mundial, consumo de medicamentos, promoción de medicamentos, gastos en medicamentos, agencias reguladoras, información médica, enfermedades

falta de fundamento científico, al menos en algún país como el Reino Unido donde un informe del Parlamento exigió en 2013 la revisión de la política de compras de dichos medicamentos y

Generalmente el tema de la epilepsia desde un paradigma clínico es el más tratado en las revistas médicas cubanas, quizás por ser el que tradicionalmente se utiliza por los