Identificación de los trastornos hemorrágicos heredados en mujeres con menorragia sin causa orgánica atendidas en la Foscal (Colombia)

Antecedentes: Aunque la menorragia es un síntoma ginecológico frecuente, en menos del 50% de las pacientes se logra identificar una causa específica. Recientemente, se ha demostrado que los trastornos hemorrágicos, en especial la enfermedad de von Willebrand (EVW), son prevalentes en estas pacientes...

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Autores:
Hinestroza Lamus, Sergio
Tipo de recurso:
Fecha de publicación:
2017
Institución:
Universidad Autónoma de Bucaramanga - UNAB
Repositorio:
Repositorio UNAB
Idioma:
spa
OAI Identifier:
oai:repository.unab.edu.co:20.500.12749/19027
Acceso en línea:
http://hdl.handle.net/20.500.12749/19027
Palabra clave:
Internal medicine
Medicine
Medical sciences
Health sciences
Menorrhagia
Inherited bleeding disorders
Von's disease Willebrand
Menstruation disorders
Hemorrhagic diseases
Ultrasound
Medicina interna
Medicina
Ciencias médicas
Trastornos de la mestruacción
Enfermedades hemorrágicas
Ecografías
Ciencias de la salud
Menorragia
Trastornos heredados de la coagulación
Enfermedad de von Willebrand
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License
http://creativecommons.org/licenses/by-nc-nd/2.5/co/
id UNAB2_61b25ac525d4351221a58753bbed794c
oai_identifier_str oai:repository.unab.edu.co:20.500.12749/19027
network_acronym_str UNAB2
network_name_str Repositorio UNAB
repository_id_str
dc.title.spa.fl_str_mv Identificación de los trastornos hemorrágicos heredados en mujeres con menorragia sin causa orgánica atendidas en la Foscal (Colombia)
dc.title.translated.spa.fl_str_mv Identification of inherited bleeding disorders in women with menorrhagia without organic cause treated in La Foscal (Colombia)
title Identificación de los trastornos hemorrágicos heredados en mujeres con menorragia sin causa orgánica atendidas en la Foscal (Colombia)
spellingShingle Identificación de los trastornos hemorrágicos heredados en mujeres con menorragia sin causa orgánica atendidas en la Foscal (Colombia)
Internal medicine
Medicine
Medical sciences
Health sciences
Menorrhagia
Inherited bleeding disorders
Von's disease Willebrand
Menstruation disorders
Hemorrhagic diseases
Ultrasound
Medicina interna
Medicina
Ciencias médicas
Trastornos de la mestruacción
Enfermedades hemorrágicas
Ecografías
Ciencias de la salud
Menorragia
Trastornos heredados de la coagulación
Enfermedad de von Willebrand
title_short Identificación de los trastornos hemorrágicos heredados en mujeres con menorragia sin causa orgánica atendidas en la Foscal (Colombia)
title_full Identificación de los trastornos hemorrágicos heredados en mujeres con menorragia sin causa orgánica atendidas en la Foscal (Colombia)
title_fullStr Identificación de los trastornos hemorrágicos heredados en mujeres con menorragia sin causa orgánica atendidas en la Foscal (Colombia)
title_full_unstemmed Identificación de los trastornos hemorrágicos heredados en mujeres con menorragia sin causa orgánica atendidas en la Foscal (Colombia)
title_sort Identificación de los trastornos hemorrágicos heredados en mujeres con menorragia sin causa orgánica atendidas en la Foscal (Colombia)
dc.creator.fl_str_mv Hinestroza Lamus, Sergio
dc.contributor.advisor.none.fl_str_mv Sossa Melo, Claudia Lucía
Osma Zambrano, Sonia Esperanza
dc.contributor.author.none.fl_str_mv Hinestroza Lamus, Sergio
dc.contributor.cvlac.spa.fl_str_mv Sossa Melo, Claudia Lucía [0001425704]
Osma Zambrano, Sonia Esperanza [0000660280]
dc.contributor.googlescholar.spa.fl_str_mv Osma Zambrano, Sonia Esperanza [hToq6yMAAAAJ]
dc.contributor.orcid.spa.fl_str_mv Osma Zambrano, Sonia Esperanza [0000-0003-4450-3147]
dc.contributor.scopus.spa.fl_str_mv Sossa Melo, Claudia Lucía [57189519230]
Osma Zambrano, Sonia Esperanza [36477836200]
dc.subject.keywords.spa.fl_str_mv Internal medicine
Medicine
Medical sciences
Health sciences
Menorrhagia
Inherited bleeding disorders
Von's disease Willebrand
Menstruation disorders
Hemorrhagic diseases
Ultrasound
topic Internal medicine
Medicine
Medical sciences
Health sciences
Menorrhagia
Inherited bleeding disorders
Von's disease Willebrand
Menstruation disorders
Hemorrhagic diseases
Ultrasound
Medicina interna
Medicina
Ciencias médicas
Trastornos de la mestruacción
Enfermedades hemorrágicas
Ecografías
Ciencias de la salud
Menorragia
Trastornos heredados de la coagulación
Enfermedad de von Willebrand
dc.subject.lemb.spa.fl_str_mv Medicina interna
Medicina
Ciencias médicas
Trastornos de la mestruacción
Enfermedades hemorrágicas
Ecografías
dc.subject.proposal.spa.fl_str_mv Ciencias de la salud
Menorragia
Trastornos heredados de la coagulación
Enfermedad de von Willebrand
description Antecedentes: Aunque la menorragia es un síntoma ginecológico frecuente, en menos del 50% de las pacientes se logra identificar una causa específica. Recientemente, se ha demostrado que los trastornos hemorrágicos, en especial la enfermedad de von Willebrand (EVW), son prevalentes en estas pacientes. Objetivo: Identificar los trastornos hemorrágicos heredados en mujeres con menorragia sin causa orgánica y establecer que variables clínicas son predictivas de estos trastornos. Escenario: Pacientes ambulatorios del servicio de ginecología y hematología de una clínica de tercer nivel en Bucaramanga, Colombia. Métodos: Se realizó un estudio observacional, descriptivo y prospectivo por la forma secuencial en la aproximación diagnóstica, entre enero del 2014 y diciembre del 2016. Un total de 38 pacientes consecutivas con diagnóstico de menorragia (menstruación > 7 días o sangrado excesivo > 80 mí por ciclo definido por PBAC > 100) sin causa ginecológica fueron estudiadas. A todas las pacientes se les realizó una ecografía pélvica y evaluación ginecológica. Se diligenció un cuestionario con datos sociodemográficos, médicos y de la historia menstrual junto a una herramienta de tamizaje para trastornos hemorrágicos. Se utilizó igualmente un pictograma (PBAC) para la valoración semiobjetiva de la perdida menstrual. Se estudiaron con hemograma, tiempo de protrombina, tiempo parcial de tromboplastina, ferritina y el perfil para la EVW. En caso de que los test iniciales fueran negativos, se continuó con la determinación de los factores de coagulación, fibrinógeno, agregometría plaquetaria y el tiempo de lisís de Euglobina. Resultados: Una alteración hemostática se identificó en 12 (32%) pacientes. De estas, 7 (19%) presentaron un trastorno hemorrágico heredado tipo EVW. Las 5 (13%) pacientes restantes presentaron bajo FVW como factor de riesgo para sangrado. Significativamente más mujeres con EVW presentaron menorragia desde la menarquia (71.4% vs 19.3%; p= 0.01), hemorragia postparto (100% vs 26.7%; p= 0.05), y sangrado post quirúrgico (66.6% vs 5.6%; p= 0.04) comparadas con las mujeres sin trastornos hemorrágicos. La frecuencia de síntomas menstruales fue significativamente mayor en mujeres con EVW dado por sensación de “chorro” en la mayoría de sus periodos (100% vs 53.9%; p= 0.02), sangrado menstrual > 8 días (57% vs 11.6%; p= 0.02) y necesidad de un mayor número de toallas higiénicas por ciclo (31 vs 24.5; p=0.04). Conclusiones: Los trastornos hemorrágicos heredados se identificaron en una proporción sustancial de mujeres con menorragia sin causa orgánica. Sugerimos que estas pacientes sean estudiadas principalmente para la EVW de forma conjunta por ginecología y hematología.
publishDate 2017
dc.date.issued.none.fl_str_mv 2017
dc.date.accessioned.none.fl_str_mv 2023-02-15T19:39:42Z
dc.date.available.none.fl_str_mv 2023-02-15T19:39:42Z
dc.type.driver.none.fl_str_mv info:eu-repo/semantics/masterThesis
dc.type.local.spa.fl_str_mv Tesis
dc.type.hasversion.none.fl_str_mv info:eu-repo/semantics/acceptedVersion
dc.type.redcol.none.fl_str_mv http://purl.org/redcol/resource_type/TM
status_str acceptedVersion
dc.identifier.uri.none.fl_str_mv http://hdl.handle.net/20.500.12749/19027
dc.identifier.instname.spa.fl_str_mv instname:Universidad Autónoma de Bucaramanga - UNAB
dc.identifier.reponame.spa.fl_str_mv reponame:Repositorio Institucional UNAB
dc.identifier.repourl.spa.fl_str_mv repourl:https://repository.unab.edu.co
url http://hdl.handle.net/20.500.12749/19027
identifier_str_mv instname:Universidad Autónoma de Bucaramanga - UNAB
reponame:Repositorio Institucional UNAB
repourl:https://repository.unab.edu.co
dc.language.iso.spa.fl_str_mv spa
language spa
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114. Federici A, Castaman G, Mannucci P. Guidelines for the diagnosis and management of von Willebrand disease in Italy. Haemophilia. 2002;8(5):607-21.
115. Castaman G, Goodeve A, Eikenboom J, European Group on von Willebrand D. Principies of care for the diagnosis and treatment of von Willebrand disease. Haematologica. 2013;98(5):667-74.
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119. Goodeve A, Eikenboom J, Castaman G, Rodeghiero F, Federici AB, Batlle J, et al. Phenotype and genotype of a cohort of families historically diagnosed with type 1 von Willebrand disease in the European study, Molecular and Clinical Markers for the Diagnosis and Management of Type 1 von Willebrand Disease (MCMDM-1VWD). Blood. 2007;109(1):112-21.
120. James PD, Notley C, Hegadorn C, Leggo J, Tuttle A, Tinlin S, et al. The mutational spectrum of type 1 von Willebrand disease: Results from a Canadian cohort study. Blood. 2007;109(1):145-54.
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dc.publisher.grantor.spa.fl_str_mv Universidad Autónoma de Bucaramanga UNAB
dc.publisher.faculty.spa.fl_str_mv Facultad Ciencias de la Salud
dc.publisher.program.spa.fl_str_mv Especialización en Medicina Interna
institution Universidad Autónoma de Bucaramanga - UNAB
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spelling Sossa Melo, Claudia Lucía090f67d5-2a77-4cbb-8a32-0c23a2487d41Osma Zambrano, Sonia Esperanza5ad113ae-4716-453c-9c1f-6fe3cd0b4d24Hinestroza Lamus, Sergioe025a159-f143-41f6-87f2-a3b71ccf0ec0Sossa Melo, Claudia Lucía [0001425704]Osma Zambrano, Sonia Esperanza [0000660280]Osma Zambrano, Sonia Esperanza [hToq6yMAAAAJ]Osma Zambrano, Sonia Esperanza [0000-0003-4450-3147]Sossa Melo, Claudia Lucía [57189519230]Osma Zambrano, Sonia Esperanza [36477836200]Floridablanca (Santander, Colombia)20172023-02-15T19:39:42Z2023-02-15T19:39:42Z2017http://hdl.handle.net/20.500.12749/19027instname:Universidad Autónoma de Bucaramanga - UNABreponame:Repositorio Institucional UNABrepourl:https://repository.unab.edu.coAntecedentes: Aunque la menorragia es un síntoma ginecológico frecuente, en menos del 50% de las pacientes se logra identificar una causa específica. Recientemente, se ha demostrado que los trastornos hemorrágicos, en especial la enfermedad de von Willebrand (EVW), son prevalentes en estas pacientes. Objetivo: Identificar los trastornos hemorrágicos heredados en mujeres con menorragia sin causa orgánica y establecer que variables clínicas son predictivas de estos trastornos. Escenario: Pacientes ambulatorios del servicio de ginecología y hematología de una clínica de tercer nivel en Bucaramanga, Colombia. Métodos: Se realizó un estudio observacional, descriptivo y prospectivo por la forma secuencial en la aproximación diagnóstica, entre enero del 2014 y diciembre del 2016. Un total de 38 pacientes consecutivas con diagnóstico de menorragia (menstruación > 7 días o sangrado excesivo > 80 mí por ciclo definido por PBAC > 100) sin causa ginecológica fueron estudiadas. A todas las pacientes se les realizó una ecografía pélvica y evaluación ginecológica. Se diligenció un cuestionario con datos sociodemográficos, médicos y de la historia menstrual junto a una herramienta de tamizaje para trastornos hemorrágicos. Se utilizó igualmente un pictograma (PBAC) para la valoración semiobjetiva de la perdida menstrual. Se estudiaron con hemograma, tiempo de protrombina, tiempo parcial de tromboplastina, ferritina y el perfil para la EVW. En caso de que los test iniciales fueran negativos, se continuó con la determinación de los factores de coagulación, fibrinógeno, agregometría plaquetaria y el tiempo de lisís de Euglobina. Resultados: Una alteración hemostática se identificó en 12 (32%) pacientes. De estas, 7 (19%) presentaron un trastorno hemorrágico heredado tipo EVW. Las 5 (13%) pacientes restantes presentaron bajo FVW como factor de riesgo para sangrado. Significativamente más mujeres con EVW presentaron menorragia desde la menarquia (71.4% vs 19.3%; p= 0.01), hemorragia postparto (100% vs 26.7%; p= 0.05), y sangrado post quirúrgico (66.6% vs 5.6%; p= 0.04) comparadas con las mujeres sin trastornos hemorrágicos. La frecuencia de síntomas menstruales fue significativamente mayor en mujeres con EVW dado por sensación de “chorro” en la mayoría de sus periodos (100% vs 53.9%; p= 0.02), sangrado menstrual > 8 días (57% vs 11.6%; p= 0.02) y necesidad de un mayor número de toallas higiénicas por ciclo (31 vs 24.5; p=0.04). Conclusiones: Los trastornos hemorrágicos heredados se identificaron en una proporción sustancial de mujeres con menorragia sin causa orgánica. Sugerimos que estas pacientes sean estudiadas principalmente para la EVW de forma conjunta por ginecología y hematología.INTRODUCCIÓN................................................................................ ............................. 14 1. DESCRIPCIÓN DEL PROYECTO............................................................................... 16 1.1 PLANTEAMIENTO DEL PROBLEMA Y SU JUSTIFICACIÓN.................................. 16 2. OBJETIVOS DEL PROYECTO................................................................................... 19 2.1 OBJETIVO GENERAL.............................................................................................. 19 2.2 OBJETIVOS ESPECÍFICOS.....................................................................................19 3. MARCO TEÓRICO Y ESTADO DEL ARTE.................................................................20 3.1 DEFINICIÓN Y CAUSAS DE MENORRAGIA...........................................................20 3.2 EVALUACIÓN DE LA PÉRDIDA DE SANGRE MENSTRUAL..................................21 3.3 FRECUENCIA DE LOS TRASTORNOS HEREDADOS HEMORRÁGICOS EN PACIENTES CON MENORRAGIA...................................................................................25 3.4 TAMIZAJE DE TRASTORNOS HEMORRÁGICOS EN MUJERES CON MENORRAGIA................................................................................................................. 29 3.5 DIAGNÓSTICO DE LOS TRASTORNOS HEMORRÁGICOS HEREDADOS . 33 4. METODOLOGIA PROPUESTA.................................................................................. 44 4.1 TIPO DE ESTUDIO...................................................................................................44 4.2. UNIVERSO Y MUESTRA........................................................................................ 44 4.2.1 Población de referencia:........................................................................................44 4.3. TAMAÑO DE LA MUESTRA....................................................................................44 4.4. CRITERIOS DE INCLUSIÓN Y EXCLUSIÓN...........................................................45 4.4.1. Criterios de inclusión............................................................................................ 45 4.4.2. Criterios de exclusión........................................................................................... 45 4.5 VARIABLES.............................................................................................................. 46 4.6 CONTROL DE SESGOS.......................................................................................... 60 4.6.1 Sesgo de selección:...............................................................................................60 4.6.2 Sesgo de memoria:................................................................................................60 4.6.3 Sesgo por falta de sensibilidad de un instrumento:................................................ 60 4.7 RECOLECCIÓN DE LA INFORMACIÓN..................................................................60 4.8 PROCESAMIENTO Y ANÁLISIS ESTADÍSTICO.....................................................62 5. CONSIDERACIONES ETICAS................................................................................... 64 5.1 ASPECTOS ÉTICOS.................................................................................................64 5.1.1. Principio de autonomía.........................................................................................64 5.1.2. Principio de confidencialidad............................................................................... 64 5.1.3. Principio de no maleficencia.................................................................................64 5.1.4. Principio de beneficencia......................................................................................64 6. RESULTADOS............................................................................................................65 6.1 CARACTERIZACIÓN DE LA POBLACIÓN.............................................................. 67 6.2 FRECUENCIA DE LOS TRASTORNOS HEREDADOS DE LA COAGULACIÓN EN MUJERES CON MENORRAGIA SIN CAUSA ORGÁNICA...................................... 68 6.3 DESCRIPCIÓN DE LAS CARACTERÍSTICAS SOCIODEMOGRÁFICAS Y CLÍNICAS DE LAS MUJERES CON MENORRAGIA SIN CAUSA ORGÁNICA Y SU ASOCIACIÓN CON LOS THH....................................................................................71 6.4 DESCRIBIR LAS VARIABLES DE LABORATORIO Y EXPLORAR SU UTILIDAD EN EL DIAGNÓSTICO DE LOS TRASTORNOS HEREDADOS HEMORRÁGICOS............................................................................................................74 6.5 EVALUAR LA UTILIDAD DE LA HERRAMIENTA DE TAMIZAJE DE PHILLIP PARA TRASTORNOS HEMORRÁGICOS EN LA POBLACIÓN CON MENORRAGIA SIN CAUSA ORGÁNICA.........................................................................77 6.6 DESCRIBIR LOS PUNTAJES OBTENIDOS EN EL PBAC Y EVALUAR SU ASOCIACIÓN CON LOS THH.......................................................................................... 78 6.7 DESCRIBIR EL COMPORTAMIENTO EN LOS NIVELES DEL FVW: AG, FVW: RCO Y FVIII SEGÚN EL GRUPO SANGUÍNEO, ETNIA, TERAPIA HORMONAL Y EDAD...............................................................................................................................82 7. DISCUSIÓN.................................................................................................................89 8. CONCLUSIONES........................................................................................................99 9. FORTALEZAS Y LIMITACIONES............................................................................. 100 BIBLIOGRAFÍA..............................................................................................................103 ANEXOS........................................................................................................................ 116EspecializaciónBackground: Although menorrhagia is a common gynecological symptom, in less than 50% of patients, a specific cause can be identified. Recently, it has been shown that bleeding disorders, especially von Willebrand disease (VWD), are prevalent in these patients. Objective: To identify inherited bleeding disorders in women with unexplained menorrhagia organic and establish which clinical variables are predictive of these disorders. Setting: Outpatients of the gynecology and hematology service of a clinic of third level in Bucaramanga, Colombia. Methods: An observational, descriptive and prospective study was carried out by the sequential form in diagnostic approach, between January 2014 and December 2016. A total of 38 patients consecutive times with a diagnosis of menorrhagia (menstruation > 7 days or excessive bleeding > 80 min per cycle defined by PBAC > 100) without gynecological cause were studied. to all patients They underwent a pelvic ultrasound and gynecological evaluation. A questionnaire was completed with sociodemographic, medical and menstrual history data together with a screening tool for bleeding disorders. A pictogram (PBAC) was also used for the assessment Semi-objective analysis of menstrual loss. Complete blood count, prothrombin time, partial thromboplastin time, ferritin, and VWD profile. In case the initial tests were negative, we continued with the determination of coagulation factors, fibrinogen, platelet aggregometry and Euglobin lysis time. Results: A hemostatic disorder was identified in 12 (32%) patients. Of these, 7 (19%) had an inherited VWD-type bleeding disorder. The remaining 5 (13%) patients presented low VWF as a risk factor for bleeding. Significantly more women with VWD presented menorrhagia since menarche (71.4% vs 19.3%; p= 0.01), hemorrhage postpartum (100% vs 26.7%; p= 0.05), and postoperative bleeding (66.6% vs 5.6%; p= 0.04) compared with women without bleeding disorders. The frequency of menstrual symptoms was significantly higher in women with VWD due to the sensation of "jet" in the majority of their periods (100% vs 53.9%; p= 0.02), menstrual bleeding > 8 days (57% vs 11.6%; p= 0.02) and need for a greater number of sanitary napkins per cycle (31 vs 24.5; p=0.04). Conclusions: Inherited bleeding disorders were identified in a proportion substantial number of women with menorrhagia without organic cause. We suggest that these patients be studied mainly for VWD jointly by gynecology and hematology.application/pdfspahttp://creativecommons.org/licenses/by-nc-nd/2.5/co/Abierto (Texto Completo)Atribución-NoComercial-SinDerivadas 2.5 Colombiahttp://purl.org/coar/access_right/c_abf2Identificación de los trastornos hemorrágicos heredados en mujeres con menorragia sin causa orgánica atendidas en la Foscal (Colombia)Identification of inherited bleeding disorders in women with menorrhagia without organic cause treated in La Foscal (Colombia)Especialista en Medicina InternaUniversidad Autónoma de Bucaramanga UNABFacultad Ciencias de la SaludEspecialización en Medicina Internainfo:eu-repo/semantics/masterThesisTesisinfo:eu-repo/semantics/acceptedVersionhttp://purl.org/redcol/resource_type/TMInternal medicineMedicineMedical sciencesHealth sciencesMenorrhagiaInherited bleeding disordersVon's disease WillebrandMenstruation disordersHemorrhagic diseasesUltrasoundMedicina internaMedicinaCiencias médicasTrastornos de la mestruacciónEnfermedades hemorrágicasEcografíasCiencias de la saludMenorragiaTrastornos heredados de la coagulaciónEnfermedad de von WillebrandOehler M, Rees M. 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Review of quality of life: menorrhagia in women with or without inherited bleeding disorders. Haemophilia. 2008;14(1):15-2014. Barr RD, Sek J, Horsman J, Furlong W, Saleh M, Pai M, et al. Health status and health-related quality of life associated with von Wíllebrand disease. Am J Hematol. 2003;73(2):108-14.15. Kirtava A, Drews C, Lally C, Dilley A, Evatt B. Medical, reproductive and psychosocial experiences of women diagnosed with von Willebrand's disease receiving care in haemophilia treatment centres: a case-control study. Haemophilia. 2003;9(3):292-7.16. Woo Y, White B, Corbally R, Byrne M, O'Connell N, O’Shea E. von Willebrand's disease: an important cause of dysfunctional uterine bleeding. Blood Coagul Fibrinolysis. 2002;13:89 -93.17. James AH, Myers ER, Cook C, Pietrobon R. Complications of hysterectomy in women with von Wíllebrand disease. Haemophilia. 2009;15(4):926-31.18. Kadir R, Lee C, Sabin C, Pollard D, Economides D. 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Pathology. 2016;48(4):303-18.ORIGINAL2017_Tesis_Hinestroza_Lamus_Sergio.pdf2017_Tesis_Hinestroza_Lamus_Sergio.pdfTesisapplication/pdf37113902https://repository.unab.edu.co/bitstream/20.500.12749/19027/1/2017_Tesis_Hinestroza_Lamus_Sergio.pdfe518b87d22b886dbd7a7b94dc7b13918MD51open accessLICENSElicense.txtlicense.txttext/plain; charset=utf-8829https://repository.unab.edu.co/bitstream/20.500.12749/19027/2/license.txt3755c0cfdb77e29f2b9125d7a45dd316MD52open accessTHUMBNAIL2017_Tesis_Hinestroza_Lamus_Sergio.pdf.jpg2017_Tesis_Hinestroza_Lamus_Sergio.pdf.jpgIM Thumbnailimage/jpeg4976https://repository.unab.edu.co/bitstream/20.500.12749/19027/3/2017_Tesis_Hinestroza_Lamus_Sergio.pdf.jpg107ab1c7333c351d09c5a0398801401aMD53open access20.500.12749/19027oai:repository.unab.edu.co:20.500.12749/190272023-02-15 22:00:53.539open accessRepositorio Institucional | Universidad Autónoma de Bucaramanga - UNABrepositorio@unab.edu.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