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Revista de la Facultad de Medicina Humana

versión impresa ISSN 1814-5469versión On-line ISSN 2308-0531

Rev. Fac. Med. Hum. vol.22 no.4 Lima oct./dic. 2022  Epub 12-Oct-2022

http://dx.doi.org/10.25176/rfmh.v22i4.5169 

Original article

Incidence of perioperative delirium at the hospital nacional arzobispo loayza, october to December 2021, Lima Peru

Carlos Gustavo Siu Wong1  , Medical specialist in Anesthesiology, Magister in Medicine

Norma Aleida Saavedra Vargas1  , Psychiatrist

Nataly Daniela Mostacero Montalvo1  , Medical specialist in Anesthesiology

Aida Milagros Arredondo Malca1  , Medical specialist in Anesthesiology

Isabel Vásquez Suyo1  , Medical specialist in Anesthesiology, Magister in Medicine

Julio Armando Ravines Villanueva1  , Anesthesiology resident doctor

Gina Milenka Pierina Altamirano Arauco1  , Anesthesiology resident doctor

1Hospital Nacional Arzobispo Loayza.

ABSTRACT

Objective:

To determine the incidence of perioperative delirium (POD) at the Hospital nacioanl Arzobispo Loayza, from October to December 2021.

Methods:

Qualitative and prospective observational study, carried out in a population of 910 patients, in which the AMT Test Confusion Assessment Method (CAM) and the Pfeiffer questionnaire (Short Portable Mental Status Questionnaire, SPMSQ) were applied. We used Chi2 to demonstrate the existence of association and Cramer's V and Phi tests to quantify the intensity of said relationship if it existed.

Results:

Of the total of patients (910), 18.46% presented perioperative delirium. Sex and religion do not inuence this. Age does inuence the presentation of POD since 50% (145) of the patients 61 years of age or older presented it, unlike those between 36 -60 years of age only 5.31% and those of 18 - 35 only 0.88% presented POD. According to the level of education: 100% with no education, 73.1% with primary education, 18.5% with secondary education and 5.8% with higher education, presented DPO. According to the anesthetic technique, POD was found in 28.9% (60) of the spinal type with sedation, 22.4% (11) of the epidural type with sedation, 16.7% (83) of the General TIVA TCI type, 12.9% (4) of the Block type with sedation, 9.5% (10) of the General balanced type; for the types of general anesthesia manual TIVA, General Multimodal and Spinal anesthesia without sedation there were no cases of POD. According to the operative time: 100% (9) of the patients with more than 6 hours of operative time, 27.1% (38) of the patients who have 3 to 6 hours of operative time and 16.5% (121) of the patients who have 1 to 3 hours of operative time presented cases of POD. According to hospitalization time prior to surgery: 48% (36) of patients with hospitalization time of 16 to 30 days, 20.5% (26) of patients with hospitalization time of 8 to 15 days and 16% (97) of the patients with hospitalization time of 3 to 7 days presented POD. According to the presence of comorbidities: 51.6% (16) with AHT and RD, 41.7% (30) with Diabetes and 40.8% (20) with AHT and DM2 present POD. According to the presence of dementia: 100% (6) of the patients with a history of dementia and 17.9% (162) of the patients with no history of dementia presented POD. According to psychiatric history, 68.4% (13) of those who did have a history of psychiatric disorder and 17.4% (155) of those who did not have a history of psychiatric disorder presented POD. According to history of psychiatric treatment: 100% (6) of those who do have a history of treatment and 17.9% (162) of those who do not have a history of psychiatric treatment presented POD. According to the pre-surgical and post-surgical PFEIFFER questionnaire: 100% of those with mild, moderate or severe cognitive impairment according to the PFEIFFER PRE QX questionnaire presented POD. According to diagnosis of pre-surgical and post-surgical delirium: 100% presented POD.

Conclusions:

There is no association between sex and religion and the presentation of POD. If there is an association between age, educational level, type of anesthesia, operative time, hospitalization time prior to surgery, comorbidities, history of dementia, history of psychiatric disorder, history of psychiatric treatment, pre-, post-surgical Pfeiffer questionnaire, pre-surgical delirium and post-surgical delirium and the presentation of POD.

Keywords: Perioperative; delirium. (Source: MESH-NLM)

INTRODUCTION

Delirium has been described in medical literature for more than two thousand years and is still not recognized, evaluated or managed appropriately1. It is also known as acute confusional syndrome, metabolic encephalopathy, or altered mental status, among 30 other descriptive terms. Delirium could be described as acute brain failure and is the end of multiple mechanisms similar to that of heart failure. The official definition of delirium is described in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)2, which mentions that a disturbance of attention and consciousness is required that develops acutely and tends to fluctuate. The pathophysiology of delirium remains in theory, it has not been possible to explain 100% but studies have included neurotransmitters such as norepinephrine and acetylcholine and neuroinflammation as its cause3,4.

Perioperative delirium is a frequent and relevant complication in surgical patients5. Its genesis is multifactorial, involving pre-existing characteristics of the patient, and triggers such as medications, pain, and inflammation associated with surgical trauma, among others6. Delirium corresponds to an acute-onset brain function disorder that can develop in hospitalized patients, especially older adults, characterized by an alteration in the level of consciousness of fluctuating course and by alterations of variable degrees in several domains of the brain. brain functioning, such as the organization of thought, the relationship with the environment, and characteristically a deficit in attention. Occasionally it manifests as motor agitation and positive mental symptoms (illusions, hallucinations), but the most frequent are the hypoactive forms and the mixed variant.

The appearance of perioperative delirium is associated with adverse outcomes, such as a longer hospital stay, a higher risk of complications, and a reduction in functionality and cognitive status in the long-term evolution6. During the last five years and after observing a high incidence of delirium, as well as its association with adverse health outcomes, this condition has become an opportunity to improve hospital care through the implementation of multimodal prevention strategies7. In the hospital setting, it continues to be poorly diagnosed and treated, and up to 80% of patients are not recognized or treated perioperatively8. It turns out to be the second most common hospital psychiatric syndrome, after depressive disorders. For the patient, it implies an association of greater morbidity, mortality, persistent functional impairment.

Delirium reaches an incidence between 15 and 50% in older adults hospitalized for medical pathology, in patients subjected to mechanical ventilation, its incidence ranges between 60 and 85%. Thus, the highest incidences of POD described are observed in patients undergoing vascular surgery, heart surgery, and in adults older than 70 years undergoing surgery for hip fracture9. In major abdominal surgery, Koebrugge et al, describe an incidence of 24%, Patti et al, document an 18% incidence of POD in older adults undergoing colon surgery for cancer, a value similar to that observed by McAlpine in women undergoing surgery for suspected gynecological cancer.

It should also be noted that delirium occurs mostly at night and can be of three types: hyperactive, hypoactive, and mixed, with hypoactive being the most frequent6. Multimodal non-pharmacological prevention strategies have documented a significant reduction in the incidence of delirium. Delirium therapy should focus on the search and management of precipitating factors, on favoring an adequate non-pharmacological environment, and on the appropriate use of neuroleptics.

The proper recognition of this entity and the implementation of non-pharmacological prevention strategies currently constitute a standard that promotes quality and safe care for surgical patients. The prevention and diagnosis of delirium are important to be able to treat it in an inter and multidisciplinary approach since it is closely related to less functional and cognitive deterioration and greater satisfaction on the part of the family.

The aim of this study is to visualize the incidence of perioperative delirium at the Hospital Nacional Arzobispo Loayza according to distribution by age, sex, religion, educational level, type of anesthesia, operative time, preoperative stay time, comorbidities, the existence of preoperative dementia, history of psychiatric disorder and history of psychiatric treatment. The tests that will be applied in this study are the Test Confusion Assessment Method (CAM) or Abbreviated Mental Test (AMT), which is a test that, observes the patient quickly, at the bedside, with simple questions of orientation in time and space allows us to diagnose delirium with 95% sensitivity and specificity.

The Pfeiffer questionnaire (Short Portable Mental Status Questionnaire, SPMSQ). , is similar to the AMT, with a little more weight for the MS and with the difference that the errors are scored, instead of the correct ones. The SPMSQ has a good performance for the detection of dementia in PC (PdC 2/3)69 and in AE (PdC 2/3)70 and excellent in the geriatric setting (PdC 4/5)71.10

METHOD

Design and study area

The present study is observational, analytical, and prospective in the period from October 1 to December 31, 2021, at the Hospital Nacional Arzobispo Loayza in Lima-Peru.

Population and sample

The sample in this period obtained by non-randomization for convenience was constituted of the entire population of patients who underwent surgery in the surgical sectors called Operations Room 6 (S06) and Operations Room 10 (S010) comprised of 910 patients.

Variables and instruments

The independent variables were studied by sex, categorized age, religion, level of education, types of sedation, operative time, and hospitalization time prior to surgery. The dependent variable was the occurrence of delirium.

Procedures

Para la recolección de datos se aplicaron los siguientes Tests: 1) AMT Test Confussion Assessment Method (CAM) que sirve para el diagnostico de delirio y 2) El cuestionario de Pfeiffer (Short Portable Mental Status Questionnaire, SPMSQ, que sirve para determinar si existe demencia . Estos 2 test que se aplicaron en 2 oportunidades, la 1ra en la evaluación pre-anestésica, donde también se obtenía el consentimiento informado, la 2da se realizaba en la noche del día de la cirugía o en la noche del día siguiente en caso de que las cirugías terminaran después de las 4 p m. (las evaluaciones nocturnas fueron después de las 6 p m).

Statistic analysis

Chi2was performed at 99% confidence, to demonstrate the existence of association and Cramer's V and Phi tests to quantify the intensity of said relationship if it existed. The survey data was entered into a database of the SPSS 26 statistical program for analysis and the preparation of relevant tables and graphs.

Ethical Aspects

The project was evaluated and approved by the Ethics Committee of the Hospital Nacional Arzobispo Loayza. The anonymity of the patients was guaranteed by coding the data. The authors also declare that the procedures followed were in accordance with the Declaration of Helsinki.

RESULTS

We worked with a total of 910 patients. It was found that the majority were female (53.4%), those over 61 years old were 31.87%, the majority were Catholic (95.38%), the majority level of education was secondary (55.93% ), the predominant type of sedation was general TIVATCI (83.23), the predominant operative time was 3 to 6 hours (80.55%), the predominant hospitalization time prior to surgery was 3 to 7 days (66.59%) (Table 1).

Table 1. Sociodemographic characteristics of a sample of patients (n: 910). 

Characteristic Perioperative delirium
n%
Gender  
Male 424 (46,59)
Feminine 486 (53,4)
Categorized age
18 to 35 years old 225 (24,73)
36 to 60 years old 395 (43,40)
61 years old or more 290 (31,87)
Religion
Catholic 868 (95,38)
Evangelical 11 (4,61)
Level of instruction
None 6 (0,66)
Primary 67 (7,36)
Secondary 509 (55,93)
Superior 328 (36,04)
Types of sedation
Spinal cord with sedation 207 (22,74)
Epidural with sedation 49 (5,38)
General TIVATCI 495 (83,23)
Blockade with sedation 31 (3,40)
balanced overall 105 (11,54)
Surgery time  
Less than 1 hour 28 (3,07)
1 to 3 hours 140 (15,38)
3 to 6 hours 733 (80,55)
More than 6 hours 9 (0,99)
Hospitalization time prior to surgery
1 to 2 days 102 (11,21)
3 to 7 days 606 (66,59
8 to 15 days 127 (13,95)
16 to 30 days 75 (8,24)

Most had no history of dementia, no history of psychiatric disorder, and no history of psychiatric treatment. Regarding the PFEIFER questionnaire, prior to surgery, the majority presented a cognitive evaluation (88.24%), and post-surgery, the majority presented a cognitive evaluation (81.54%). Regarding the evaluation of the diagnosis of delirium, prior to surgery, those who had a diagnosis of delirium were 1.54% and post-surgery they were 3.08%. Those who presented perioperative delirium were 18.46% (Table 2).

Table 2.  Characteristicsof mental problems in a sample of patients (n: 910). 

History of dementia  
No 904 (99,34)
Yes 6 (0,66)
History of psychiatric disorder
No 891 (97,91)
Yes 13 (2,09)
History of psychiatric treatment
No 901 (99,01)
Yes 6 (0,99)
PFEIFFER Pre Qx Questionnaire
Cognitive assessment 803 (88,24)
Mild cognitive impairment 90 (9,89)
Moderate cognitive impairment 4 (0,44)
Severe cognitive impairment 13 (1,43)
PFEIFFER Post Qx Questionnaire
Cognitive assessment 742 (81,54)
Mild cognitive impairment 141 (15,50)
Moderate cognitive impairment 14 (1,54)
Severe cognitive impairment 13 (1,43)
Pre Qx delirium diagnostic evaluation
yes delirium 14 (1,54)
Not delirium 896 (98,46)
Post Qx delirium diagnostic evaluation
yes delirium 28 (3,08)
Not delirium 882 (96,92)
Perioperative delirium  
No 742 (81,54)
Yes 168 (18,46)

It was observed that women had 16.20% and men 20.3% of presenting perioperative delirium. Patients aged 61 years and over had 50%; Regarding religion, Catholics had 18%; and those who had a primary education level were the ones who most presented this condition (63.64%). The types of sedation that prevailed were spinal (28.99%) and epidural (22.45%). The hospitalization time prior to surgery that prevailed were 16-30 days (48%) and 8-15 days (20.5%). However, there was no association between the variables.

Table 3 Bivariateanalysis of the characteristics associated with perioperative delirium in a sample of patients. 

Characteristics Perioperative delirium
No Yes p*
n% n%
  742 (81,54%) 168 (18,46)  
Gender     0,186*
Male 338 (79,7) 86 (20,3)  
Feminine 404 (83,1) 82 (16,9)  
Categorized age     0,558*
18 to 35 years old 223 (99,12) 2 (0,88)  
36 to 60 years old 374 (94,69) 21 (5,31)  
61 years old or more 145 (50) 145 (50)  
Religion   0,186*
Catholic 711 (82) 157 (18)  
Evangelical 11 (100) 0 (0)  
Level of instruction     0,462*
None 0 (00) 6 (100)  
Primary 18 (36,36) 49 (63,64)  
Secondary 415 (81,53) 94 (18,47)  
Superior 309 (94,21) 19 (5,79)  
Types of sedation     0,456
Spinal cord with sedation 147 (71,01) 60 (28,99)  
Epidural with sedation 38 (77,55) 11 (22,45)  
General TIVATCI 412 (83,23) 83 (16,77)  
Blockade with sedation 27 (87,10) 4 (12,9)  
balanced overall 95 (90,48) 10 (9,52)  
Surgery time      0,246*
Less than 1 hour 28 (100) 0 (0)  
1 to 3 hours 102 (72,9) 38 (27,1)  
3 to 6 hours 612 (83,5) 121 (16,5)  
More than 6 hours 0 (0) 9 (100)  
Hospitalization time prior to surgery     0,372
1 to 2 days 93 (91,18) 9 (8,82)  
3 to 7 days 509 (84) 97 (16)  
8 to 15 days 101 (79,5) 26 (20,5)  
16 to 30 days 39 (48) 36 (48)  

It was observed that those who had a history of dementia had 100% and those who had a history of psychiatric disorder had 68.4%; those with a history of psychiatric treatment had 66.67%; the PFEIFFER questionnaire pre Qx mild, moderate, severe deterioration were the majority. Pre-Qx diagnostic evaluation of delirium was the majority and those who had a post-Qx diagnostic evaluation of delirium were the majority. However, there was no association between the variables.

Table 4. Bivariate analysis of the characteristics of mental problems associated with perioperative delirium in a sample of patients. 

History of dementia 0.171*
No 742 (82,1) 162 (17,9)
Yes 0 (0) 6 (100)
History of psychiatric disorder 0.188*
No 736 (82,6) 155 (17,4)
Yes 6 (31,6) 13 (68,4)
History of psychiatric treatment 0.171*
No 739 (82,1) 162(17,9)
Yes 3 (33,33) 6 (66,67)
PFEIFFER Pre Qx Questionnaire 0.767*
Cognitive assessment 742 (92,41) 61 (7,59)
Mild cognitive impairment 0 (0) 90 (100)
Moderate cognitive impairment 0 (0) 4 (100)
Severe cognitive impairment 0 (0) 13 (100)
PFEIFFER Post Qx Questionnaire 1.000
Cognitive assessment 742 (100) 0 (0)
Mild cognitive impairment 0 (0) 141 (100)
Moderate cognitive impairment 0 (0) 14 (100)
Severe cognitive impairment 0 (0) 13 (100)
Pre Qx delirium diagnostic evaluation 0,263
yes delirium 0 (0) 14 (100)
Not delirium 742 (82,81) 154 (17,19)
Post Qx delirium diagnostic evaluation 0,374
yes delirium 0 (0) 28 (100)
Not delirium 742 (84,13) 140 (15,87)

* Performed with the chi square test of independence

DISCUSSION

From the bibliographic reviews carried out, very few statistics related to general populations (18 to 64 years) have been found, so it is very difficult to carry out a discussion in this age group, the vast majority of publications refer to people over 65 years of age. In the present study, it was found that of the total number of patients (910), 18.4% presented POD similar to that found by Lucia Alvarez-Bastidas11, 42% according to Cristina Arotce12. This difference stands out because in our group of The study ranges from 18 years old and over and those from Arotce are all over 65 years old, but in our age group of over 61 years old, 50% did present POD, a figure similar to that of Arcotce, according to the chi-square test, obtaining a significance of 0 and Cramer's V test obtaining a value of 0.558, demonstrating a median association between age and POD. These results coincide with many works 6,11,13,14.

Regarding gender, the highest incidence of POD that we found was 20.3% (86) of men and 16.9% (82) of women presented cases of POD, as mentioned by Williams-Russo P15and Fisher BW16where it is mentioned that male sex is a predisposing factor for the development of delirium in patients undergoing orthopedic surgery, but only in those without previous dementia. In this study, the Chi-square test was performed, obtaining a significance of 0.186, rejecting an association between cases of POD and sex. Regarding religion, 18.1% (157) of the Catholics and 26.2%11of the Evangelicals presented cases of perioperative delirium, and a significance of 0.186 was obtained using Chi2, rejecting association; Between the cases of POD and religion, no other works related to this variable were found, so these results could not be discussed. According to the level of education, we found that the lower the level of education, the greater the possibility of presenting POD, so much so that 100% of those who did not have any level of education presented POD and only 5.8% of those with higher education presented it.In the work of Lucia Álvarez-Bastidas, she also mentions that lack of schooling are socioeconomic factors that are associated with said pathology11.

According to the type of anesthesia: 28.9% (60) of the spinal type with sedation presented POD, 22.4% (11) of the epidural type with sedation presented POD, 16.7% (83) of the General TIVA type TCI presented POD, 12.9% 4 of the Block type with sedation presented DPO 9.5% (10) of the General balanced type presented POD 9.5% (10) of the General balanced type presented DPO on 9, 5% (10) of the balanced General type presented POD. For the types of general anesthesia manual TIVA, General Multimodal and Spinal anesthesia without sedation, there were no cases of POD; no studies could be found with this stratification of anesthetic techniques, so it cannot be compared with other studies: it should be mentioned that according to SE Masson there would be no impact of general and regional anesthesia on the incidence of postoperative cognitive dysfunction 17-19. According to the operative time: 100% (9) of the patients with more than 6 hours of operative time, 27.1% (38) of the patients who have 3 to 6 hours of operative time and 16.5% (121) of patients who have 1 to 3 hours of operative time presented POD, it has not been possible to find bibliography in which the operative time is related to the presence of POD, but what we can infer is that the longer the operative time, the greater the possibility that changes in cerebral perfusion occur, which could condition the release of proinflammatory mediators (interleukins and tumor necrosis factor α(20, 21), which in patients with increased permeability of the blood-brain barrier, such as elderly patients, cross it causing neuronal damage (ranging from dysfunction to neuronal death), producing the subsequent clinical presentation as short- or long-term delirium, postoperative cognitive dysfunction, or dementia. Said neuroinflammation will determine an alteration of neurotransmission, with a decrease in the release of acetylcholine41 and an increase in the levels of dopamine, gamma amino butyric acid (GABA), serotonin, and norepinephrine.

Additionally, surgical stimulation increases plasma cortisol levels, which can maintain or cause POD19. According to hospitalization time before surgery: 48% (36) of patients with hospitalization time of 16 to 30 days, 20.5% (26) of patients with hospitalization time of 8 to 15 days, and 16% (97) of the patients with a hospitalization time of 3 to 7 days presented POD. Vibeke Juliebo mentions that one of the predisposing factors for POD is the long hospital stay before surgery, this is understandable since hospitals are institutions that are foreign to patients, and anguish, pain, worries, uncertainties, deprivation of family members who are also predisposing factors for POD. According to comorbidities: 51.6% (6) have hypertension and RD, 41.7% (30) have diabetes and 40.8%20have hypertension and DM2 have cases of delirium. According to Jimana Rodriguez 6,19, they report that comorbidities in patients predisposed to the appearance of POD, with the results we have that those with more comorbidities have a higher risk of presenting POD, as we see in those with high blood pressure + kidney disease. They have a higher risk than diabetics, which would prove this relationship.

According to the presence of dementia: 100%6of the patients who did have a history of dementia presented POD and 17.9% (162) of those who did not have dementia presented DPO; according to Jimena Rodríguez6mentions that patients who have dementia or another brain disease have a higher risk of presenting POD. This work agrees with this statement since 100% of the patients who presented dementia had POD. According to the history of psychiatric disorder: 68.4%13of those who do have a history of psychiatric disorder and 17.4% (155) of those who do not have a history of psychiatric disorder presented POD cases of perioperative delirium. Jimena Rodríguez6mentions that patients who have dementia or another brain disease have a higher risk of presenting POD, a concept that we see very similar since 68.4% who had brain disease presented POD. According to whether they had psychiatric treatment: 100%6of those who did have a history of psychiatric treatment and 17.9% (162) of those who did not have a history of psychiatric treatment presented POD. These figures cannot be compared since We have not found a bibliography for this variable. According to the PFEIFFER PRE QX questionnaire: 100% of those with mild, moderate or severe cognitive impairment according to the PFEIFFER PRE QX questionnaire all presented POD: from the bibliographic reviews carried out we have not been able to find comparative studies between the CAM and the Pfeiffer7, but that if we can get closer to the idea that those with cognitive mental impairment are going to present POD.

According to the PFEIFFER POST QX questionnaire, 100% of those with mild, moderate or severe cognitive impairment present cases of perioperative delirium. From the literature reviews carried out, we have not been able to find comparative studies between the CAM and the Pfeiffer, but what we can predict is that those with cognitive mental impairment will present POD. According to pre-X-ray delirium diagnostic evaluation: 100% (28) of those who were positive in the pre-X-box delirium diagnostic evaluation and 15.9% (140) of those who were negative in the delirium diagnostic evaluation pre-QX present POD, so we can infer that those with pre-QX delirium will also present POD.

CONCLUSIONS

Advanced age, low education level, long surgery time, prolonged hospitalization prior to surgery, the presence of comorbidities such as high blood pressure, kidney disease, diabetes, and diseases that affect mental health, have influenced the presentation of DPO. In the same way, the anesthesia technique could influence the appearance of POD, with the regional ones with sedation presenting the highest POD, followed by TIVA in TCI, then blockade with sedation, then balanced general anesthesia, the ones with the highest risk: this does not is supported by the international bibliography. Sex and religion do not influence the appearance of this condition.

In relation to the pre-surgical Pfeiffer questionnaire, we have that those who have presented mild, moderate or severe deterioration all have presented POD, being a high association. In relation to the post-surgical Pfeiffer questionnaire, we have that those who have presented mild, moderate, or severe deterioration all have presented POD, being a strong association.

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Funding sources: Self-funded.

8Article published by the Journal of the faculty of Human Medicine of the Ricardo Palma University. It is an open access article, distributed under the terms of the Creatvie Commons license: Creative Commons Attribution 4.0 International, CC BY 4.0(https://creativecommons.org/licenses/by/1.0/), that allows non-commercial use, distribution and reproduction in any medium, provided that the original work is duly cited. For commercial use, please contact revista.medicina@urp.edu.pe.

Received: May 03, 2022; Accepted: October 06, 2022

Correspondence: Dr. Carlos Gustavo Siu Wong. Address: Av. Alfonso Ugarte 848, Lima 15082 - Perú. Telephone number: 998670820 E-mail:carlossiuwong@yahoo.com

Authorship contributions: The authors declare to be managers of the manuscript in its entirety.

Conflicts of interest: The authors declare not to have any interest conflicts.

Creative Commons License Este es un artículo publicado en acceso abierto bajo una licencia Creative Commons