monografia factores de riesgo de amputacion en pie diabetico

7/25/2019 Monografia Factores de Riesgo de Amputacion en Pie Diabetico

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UNIVERSIDAD NACIONAL DE TRUJILLO

FACULTAD DE MEDICINASEGUNDA ESPECIALIZACIÓN

MONOGRAFÍA:

“FACTORES DE RIESGO DE AMPUTACIÓN EN PIE DIABÉTICO”

ALUMNO: Torres Ror!"#e$% S#&&' E&o!s(

AÑO: )ero

RESIDENCIA: Me*+*,( I,-er,(

PROMOCIÓN: ..

TRUJILLO / PER01234

1



MONOGRAFÍA: “FACTORES DE RIESGO DE AMPUTACIÓN EN PIEDIABÉTICO”

ÍNDICE:

35 INTRODUCCIÓN555555555555555555555555555555555555555555555555555555555555555555555555555555555555555 )

15 EPIDEMIOLOGÍA555555555555555555555555555555555555555555555555555555555555555555555555555555555555555 6

)5 PATOGENIA55555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555 6

65 FISIOPATOLOGÍA55555555555555555555555555555555555555555555555555555555555555555555555555555555555555 46535 FISIOPATOLOGÍA DEL PIE DIABÉTICO NEUROP7TICO5555555555555555 46515 FISIOPATOLOGÍA DEL PIE DIABÉTICO IS8UÉMICO5555555555555555555555 9

45 FACTORES DE RIESGO DE AMPUTACIÓN EN PIE DIABÉTICO5555555555

;5 ESTUDIOS REALIZADOS ACERCA DE FACTORES DE RIESGO DE AMPUTACIÓN EN PIE DIABÉTICO5555555555555555555555555555555555555555555555555555555555 33

95 AMPUTACIÓN EN EL PIE DIABÉTICO55555555555555555555555555555555555555555555555555555 3)

5 CONCLUSIONES55555555555555555555555555555555555555555555555555555555555555555555555555555555555555 36

<5 RECOMENDACIONES555555555555555555555555555555555555555555555555555555555555555555555555555555 39

325REFERENCIAS BIBLIOGR7FICAS55555555555555555555555555555555555555555555555555555555 3

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1. INTRODUCCIÓN

L( *(=e-es >e&&*-#s ?DM@ +o,s-*-#'e #, ro=&e>( e s(&# =&*+( ( ,*e&>#,*(& ' se +(r(+-er*$( or s# (&-( -(s( e >or=*>or-(&*(% (&-os +os-os '+o>&*+(+*o,es +r,*+(s5 ?3@

L( re(&e,+*( e *(=e-es >e&&*-#s es- (#>e,-(,o >(r+((>e,-e ( ,*e&>#,*(& +o,s*er,ose&e #,( e*e>*( e& ,#eo >*&e,*o5 Es-e (#>e,-o see=e r*,+*(&>e,-e (& >('or ,>ero e +(sos ,#eos +o, *(=e-es >e&&*-#s-*o 1% ese+*(&>e,-e e,es ' o=esos5 ?1@

De,-ro e &(s +o>&*+(+*o,es +r,*+(s se es-(+( e& *e *(=-*+o ?PD@ 5H#ese e*,e +o>o &( (&-er(+*, +&!,*+( e =(se e-*o(-o",*+(% ,e#ro-*+(%*,#+*( or *er"&*+e>*( >(,-e,*(% e, &( H#e% +o, o s*, +oeK*s-e,+*( e*sH#e>*( ' re*o ese,+(e,(,-e -r(#>-*+o% se ro#+e, &es*o,es 'o#&+er(+*o,es% or &o -(,-o% se or>( #, *e e, "r(, >(,er( *,se,s*=&e '

>#+o >s s#s+e-*=&e e &es*, or eH#eos -r(#>(-*s>os +o,-*,#(os%+o>o &os H#e se "e,er(, #r(,-e &( >(r+(5 Es-( e,-*( ,oso&"*+( es-+o,*+*o,(( or >&-*&es (+-ores +o>o so,: (#>e,-o e &( *s+os*(s(,"#!,e(% (o e,o-e&*(&% (-ero",es*s +o, (-eroes+&eros*s (+e&er(( '(&-er(+*o,es e &os (+-ores e +o("#&(+*,5 ?)% 6% 4% ;@

Es-( &es*, o #&+er(+*, -*e,e ( *,e+-(rse e, or>( seer( or &( &or(o&*>*+ro=*(,( ' o+(s*o,( >('ores >or=*>or-(&*( ' +os-os5 As!% 34 e&os *(=-*+os es(rro&&(r &es*o,es e, e& *e e, (&", >o>e,-o e &(e,er>e(5 ?3@

E& *e *(=-*+o +o,s-*-#'e e,-o,+es #, ro=&e>( e s(&# =&*+( or s#re(&e,+*(% #es e& r*es"o e -e,er #,( &+er( *(=-*+( es s#er*or (& es#r*r #, *,(r-o e >*o+(r*o ' or s#s e,or>es +os-os s(,*-(r*os% -(,-o es(s! H#e e& re+*o e #, *,"reso or (&", ro=&e>( re&(+*o,(o +o, e& *e*(=-*+o eH#*(&e ( #, -r(-(>*e,-o *,-e"r(& e &( DM H#e *,+&#'e +o,s#&-(s%(,&*s*s% >o,*-or*$(+*, ' >e*+(+*, e,-re o-ros% #r(,-e 12 (os5 ?)% 4% 9@

L(s &+er(s ' &( (>#-(+*, e &(s eK-re>*(es *,er*ores so, &( r*,+*(&+(#s( e >or=*&*(% *s+((+*( ' +os-os (r( &os *(=-*+os5 Se (es-*>(o H#e e& 12 e &( os*-(&*$(+*, (-r*=#*(s ( DM so, e& res#&-(o

e &+er(s e *,e++*, e& *e ' se +(&+#&( H#e e& 42 e &(s (>#-(+*o,es#*er(, ser e*-((s5 ?3% % <% 32@

Por &( or>( e, H#e se +o>or-( &( er*( e& *e *(=-*+o e, res#es-( (&-r(-(>*e,-o +o, oK!"e,o *er=r*+o% se #ee rese,-(r +o, e& #so e s-eoK!"e,o *s>*,#+*, e, &( *,+*e,+*( e (>#-(+*o,es o se *s>*,#'e e&,*e& e (>#-(+*,5 ?33@

Se", e& >e-((,&*s*s re(&*$(o e, &( +&!,*+( M('o e, Fe=rero e& 123)% se+o,+&#'e H#e e& -r(-(>*e,-o +o, oK!"e,o *er=r*+o re#+e &( ,e+es*( e(>#-(+*, >('or e, (+*e,-es +o, *e *(=-*+o5 ?31@

3



2. EPIDEMIOLOGÍA

Se es-*>( H#e ( ,*e& >#,*(& (' #,( re(&e,+*( e 342 >*&&o,es eerso,(s +o, *e *(=-*+o% &o H#e +o,s-*-#'e e& 154 e &( o=&(+*,>#,*(&% &o H#e rerese,-( e, (&"#,os (!ses% e& 14 e *,"resos

os*-(&(r*os5 ?3)@

E, EE UU% se +(&+#&( #, "(s-o e 122 >*&&o,es e &(res (,#(&es e, &((-e,+*, e& PD5 ?36@

L(s +o>&*+(+*o,es e, e& *e *(=-*+o so, &( r*,+*(& +(#s( e (>#-(+*,e, >*e>=ros *,er*ores ?se es-*>( e, 34222 +(sos (& (o@ ' &( se"#,(+(#s( e *,(&*e$ es#s e &os (++*e,-es5 ?4% 34@

L( >('or!( e &os (+*e,-es es(rro&&( ro=&e>(s e *e *(=-*+o ( (r-*r e&( +#(r-( +(( e &( *( H#e se *,+re>e,-(, +o, &( e(5 ?3;@

Se", &os es-#*os NDS ' NIS% &( -(s( e (>#-(+*o,es e, o>=res ess#er*or ( &( reor-(( e, >#eres5 Los o>=res -*e,e, 356 159 e+es >sr*es"o e (>#-(+*o,es H#e &(s >#eres5 ?39@

D(-os e (>#-(+*o,es e =(se o=&(+*o,(& e Ro+es-er ?M*,,eso--( EUA@ reor-(, H#e e& r*es"o e (>#-(+*o,es e >*e>=ros *,er*ores e,*(=-*+os es e ; ( &os 12 (os ' e 33 ( &os )2 (os e eo&#+*,5 ?;%39@

3. PATOGENIA

L(s &+er(s #ee, -e,er #, or*"e, ,e#ro-*+o ?92@% (s+#&o-*+o ?12@o >*K-o ?32@Q se s(=e H#e 4 e &os *(=-*+os H#e s#re, (>#-(+*o,es%re*(>e,-e (, (e+*o #,( &+er(5 ?6% % 3)@

?1@

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L(s r($o,es e& (#>e,-o e &( *,+*e,+*( e es-os -r(s-or,os e, &( DMs#o,e, &( *,-er(++*, e (r*os (+-ores (-o",*+os: ,e#ro(-!(%=*o>e+,*+( (,or>(& e& *e% e,er>e( (s+#&(r er*r*+( ?PAD@ '+*+(-r*$(+*, e*+*e,-e e &(s er*(s5 ?3@

L( ,e#ro(-!( se,s*-*( er*r*+( *,-er*ere e, &os >e+(,*s>os ,or>(&es ero-e++*, ' er>*-e H#e e& (+*e,-e s#r( -r(#>(-*s>os *>or-(,-es o &eesree-*os% H#e ( >e,#o (s(, *,(er-*os5 ?3@

Los -r(s-or,os e &( se,s*=*&*( ro*o+e-*( +(#s(, #, soor-e (,or>(&e& eso #r(,-e &( >(r+(% +o, &( +o,s*"#*e,-e or>(+*, e +(&&os*(es o#&+er(s5 L( ,e#ro(-!( >o-or( ' se,s*-*( +o,#+e ( #,( >e+,*+( (,or>(&e &os >s+#&os e& *e ' ( (&-er(+*o,es es-r#+-#r(&es e& *e ?eo e,>(r-*&&o% eor>*( e& *e e, "(rr(% ro>*,e,+*( e &(s +(=e$(s e &os>e-(-(rs*(,os% (r-*+#&(+*, e C(r+o-@5 ?3@

L( ,e#ro(-!( e"e-(-*( roo+( (,*ros*s ' (&-er( e& &#o s(,"#!,eos#er*+*(& e& *e% &o H#e ro>#ee &( ese+(+*, e &( *e& ' &( or>(+*,e *s#r(s5 L( e,er>e( (s+#&(r er*r*+( ' &( +*+(-r*$(+*, e*+*e,-e*>*e, &( reso&#+*, e eH#e(s er*(s e &( *e&%er>*-*e,o H#e(#>e,-e, e -(>(o ' se *,e+-e,5 ?3@

Los ,*e&es "&*+>*+os so, e*e,-e>e,-e #,o e &os (+-ores (-o",*+os>s *>or-(,-es e, &(s +o>&*+(+*o,es e& *(=-*+o +o>o se(&(, >&-*&eses-#*os5 ?39@

4. FISIOPATOLOGÍA

4.1. FISIOPATOLOGÍA DEL PIE DIABÉTICO NEUROPÁTICO

L( *er"&#+e>*( +r,*+( es e& (+-or e r*es"o >s *>or-(,-e (r( e&es(rro&&o e &( ,e#ro(-!(5 EK*s-e, os -eor!(s e-*o(-o",*+(s: #,(>e-(=&*+( ' o-r( (s+#&(r% (#,H#e ro=(=&e>e,-e se( &( *,-er(++*, e(>=(s &o H#e &( ro#$+(5?36@I,*+*(&>e,-e se (&-er(, &(s *=r(s ,er*os(s eH#e(s ?*=r(s se,s*-*(s@roo+(,o &( r*( e &( se,s(+*, e o&or ' -e>er(-#r( '% >s

-(re% &(s *=r(s ,er*os(s "r(,es% *s>*,#'e,o e& #>=r(& eer+e+*, e *=r(+*,5 ?36@L( ,e#ro(-!(>o-or( ro#+e *o-ro*( >#s+#&(r ((re+*e,o eos e,>(r-*&&o ' e, "(rr( H#e (ore+e, &( ro-r#s*, e &(s +(=e$(s e &os>e-(-(rs*(,os5 ?36@L( ,e#ro(-!( (#-o,>*+( ro#+e seH#e( ' *s#r(s e, &( *e& or (e+-(+*, e&(s *=r(s s*>-*+(s os"(,"&*o,(res e &(s "&,#&(ss#or!(r(s% (#>e,-o e& &#o s(,"#!,eo or (er-#r( e+o>#,*+(+*o,es (r-er*o e,os(s H#e *s>*,#'e, &( er#s*, e &( re+(*&(r ' (#>e,-(, &( -e>er(-#r( e &( *e&% &o H#e ( &#"(r ( #,-r(s-or,o os-#r(& e, &( re"#&(+*, e& &#o +o, #,( res#es-(

*,&(>(-or*( (,or>(& re,-e ( &( ("res*, ( &os -e*os5 T(>=*, ('ee>( ,e#ro-*+o ' (#>e,-o e &( res*, e,os(5?36@

5



L( os-eo(r-ro(-!( ,e#ro-*+( o *e e C(r+o- es #,( e &(s eores+o,se+#e,+*(s e &( DM e, e& *e5 P#ee e,+o,-r(rse e, #,( (se("#( H#e #ee +o,#,*r +o,*,e++*, o e, #,( (se eor>(,-e+r,*+( ' ro"res*( +(r(+-er*$(( or &( es-r#++*, *,o&or( e #esos' (r-*+#&(+*o,es5?36@

L( ,e#ro(-!(% +o, o s*, *sH#e>*( (so+*((% es- *>&*+(( e, &(*s*o(-o&o"!( e &( &+er( e& PD e, e&4 ( <2 e &os +(sos5 Por -(,-o% e& *e *,se,s*=&e% se( =*e, er#,*o o *sH#>*+o% e=e+o,s*er(rse +o>o e (&-o r*es"o e &+er(5?36@

?3<@

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4.2. FISIOPATOLOGÍA DEL PIE DIABÉTICO ISUÉMICO

E, es-e ro=&e>( se #ee, o=ser(r os (&-er(+*o,es5 E, r*>er &#"(r%&( >(+ro(,"*o(-!( *(=-*+( H#e es &( (-eros+&eros*s e, &os (+*e,-es*(=-*+os5?36@

L( >(+ro(,"*o(-!( es- *>&*+(( e, &( e-*o(-o"e,*( e &( &+er( e&PD e, 62 ( 42 e &os +(sos% "e,er(&>e,-e (so+*(( ( ,e#ro(-!(5?36@

E, se"#,o &#"(r% &( >*+ro(,"*o(-!( *(=-*+( H#e eK*s-e #,( (>&*(+o,-roers*( so=re &( *>or-(,+*( re(& e &( >*+ro(,"*o(-!( e, &(*s*o(-o&o"!( e& PD5?36@

L( "(,"re,( *"*-(& +o, #&sos *s-(&es ,o es se+#,(r*( ( &(>*+ro(,"*o(-!( s*,o ( -ro>=os*s or -oK*,(s =(+-er*(,(s ,e+ro-*$(,-es%

+o>o &(s e S-('&o+o++#s(#re#s5?36@

L( >*+ro(,"*o(-!( *(=-*+( se *>&*+( e, &( (-o"e,*( e &( &+er(,e#ro-*+(5 S*, e>=(r"o% &(s &es*o,es ,e#ro-*+(s e& PD so, *"#(&es( (H#e&&(s H#e ((re+e, e, &(s ,e#ro(-!(s ere*-(r*(s e &os ,o*(=-*+os o e, &(s ,e#ro(-!(s os-r(#>-*+(s% o,e &(>*+ro(,"*o(-!( ,o eK*s-e5?36@

O-ros (+-ores re*so,e,-es (r( &( *sH#e>*( -*s#&(r so,:

F(+-ores e>(-o&"*+os: *er*=r*,o"e,e>*(% (#>e,-o e &(("re"(+*, &(H#e-(r*(% *s>*,#+*, e &( (+-**( *=r*,o&!-*+(%re#++*, e &( eor>(=*&*( e &os "&=#&os roos ' &e#+o+*-os% e-+5

A&-er(+*, e& s*s-e>( *,>#,*-(r*o: +(>=*os e, &( *(es*s% &((ere,+*( &e#+o+*-(r*(% &( H#*>*o-(K*s% &( ("o+*-os*s ' &( &*s*s*,-r(+e&#&(r e&os "r(,#&o+*-os% H#e se ("r((, or e& >(& +o,-ro& e &("&#+e>*(5 U,( r(++*, e &os >o,o,#+&e(res +#>&e #, ro& >#'*>or-(,-e e, &( re(r(+*, e&(s er*(s *sH#>*+(s or (,"*o",es*s -er(#-*+(5

G&#+os*&(+*, ,o e,$*>-*+( e& -e*o +o,e+-*o er*(r-*+#&(r H#ero#+e r*"*e$ (r-*+#&(r% ' e &(s ro-e!,(s e& +o&"e,o H#e (+e,s#s *=r(s >s r!"*(s ' se,s*=&es (& ro+e% ' +(#s(, #, re-r(so e &(+*+(-r*$(+*, ?36@

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?3<@

!. FACTORES DE RIESGO DE AMPUTACIÓN EN PIE DIABÉTICO

Los (+-ores e r*es"o e #&+er(s e, e& *e o e (>#-(+*, +o>re,e,:seKo >(s+#&*,o% *(=e-es 32 (os e #r(+*,% ,e#ro(-!( er*r*+(%

es-r#+-#r( (,or>(& e& *e ?(&-er(+*o,es se(s% +(&&o% e,"ros(>*e,-o e &(s#(s@% e,er>e( (s+#&(r er*r*+(% -(=(H#*s>o% (,-e+ee,-es e &+er(o (>#-(+*, ' +o,-ro& e &( "&#+e>*( e*+*e,-e5 L(s "r(,es +(&&os*(ess#e&e, re+eer ( &(s #&+er(s o s#ero,erse ( e&&(s5 ?3@

A& (,(&*$(r &( re+#e,+*( e &(s (>#-(+*o,es se o=ser( H#e e& r*es"o e(>#-(+*, se *,+re>e,-( +o, &( e( ' H#e es os ( -res e+es >('or e,H#*e,es -*e,e, 64 ( ;6 (os ' s*e-e e+es >('or e, &(s erso,(s +o, >se ;4 (os e, +o>(r(+*, +o, &os >e,ores e 64 (os5 ?12@L( (#se,+*( e se,s*=*&*( *=r(-or*( ( s*o reor-(( +o>o (+-or er*es"o (r( (>#-(+*, e >*e>=ros *,er*ores5?36@

8



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RIS" FACTORS FOR TOE AMPUTATION

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#. ESTUDIOS REALI$ADOS ACERCA DE FACTORES DE RIESGO DEAMPUTACIÓN EN PIE DIABÉTICO

E, T(*,% e, &( +*#( e C(," G#,"% se re(&*$ #, es-#*o or S#, J% '+o&5 e,+o,-r H#e e& +o,-eo e +&#&(s =&(,+(s ?e>o"r(>(@ 33 222 K >> 1

es- (so+*(o +o, e& r*es"o e (>#-(+*, e &( eK-re>*( *,er*or e,(+*e,-es +o, *e *(=-*+o ?OR: 3534 3533 / 353<@ ' e& (&-o "r(o e &(

+&(s**+(+*, e (",er ? ≥ "r(o )@ es- #er-e>e,-e (so+*(o +o, e&

r*es"o *,+re>e,-(o e (>#-(+*, e &( eK-re>*( *,er*or e, (+*e,-es+o, *e *(=-*+o ?OR: 3)53 Q :96 / 3<5;4@ ?19@

E, Ir,% e, &( +*#( e A($% se &&e ( +(=o #, es-#*o or o"(,*% ' +o&5>os-r(ro, &os (+-ores H#e +o,#+e, ( &( (>#-(+*, e, (+*e,-es +o, *e*(=-*+o: seKo e>e,*,o ?OR: 59 Q 15; / 195<3@% >o,*-or*$(+*, e &os,*e&es e =A3+ >e,os e 1 e+es or (o ?OR: 3)5< Q 65<9 / )<51;@% #soe $((-os *,(e+#(os ?OR: 454 Q 1512 / 3)599@% #>(r ?OR: )%6 Q 3564 /53)@ ' #,( *s-or*( (>*&*(r e *(=e-es ?OR: )5< Q 365< / 3254)@5 ?11@

E, A&e>(,*( e, &( +*#( e Ber&!,% se re(&*$ #, es-#*o or Ps+erer% ' +o&%

>os-r(ro, H#e &( e,er>e( (r-er*(& er*r*+( #e #, (+-or s*",**+(-*o e*,ee,*e,-e >#' #er-e e (>#-(+*, e, &os (+*e,-es *(=-*+os +o,&+er(s e& *e ?OR: 453 Q 6519 / ;53;@5 Ae>s e,+o,-r(ro, H#e &os(+*e,-es +o, #, ,*e& e e>o"&o=*,( "&#+os*&(( or e,+*>( e 954 -e,!(,#, 12 >s e r*es"o e (>#-(+*, e, +o>(r(+*, +o, &os (+*e,-es or e=(o e 954% ' H#e &( o&*,e#ro(-!( *(=-*+( #e #, (+-or e r*es"o or (>#-(+*, e, (+*e,-es *(=-*+os ?OR5 35 Q 3542 / 1526@5 ?1@

E, Es((% e, &( +*#( e V(&e,+*(% se re(&*$ #, es-#*o or Re(& Co&&(o%' +o&% e>os-r(ro, &os (+-ores (so+*(os +o, (>#-(+*,% e, (+*e,-es*(=-*+os +o, #&+er(+*, e, *e: A,-e+ee,-es erso,(&es e (>#-(+*,re*( ?OR: )59 Q 3523 / 3)592@% &( rese,+*( e (s+#&o(-!( er*r*+( "r(e?OR: 953 Q 35 / 19512@ e *,e++*, "r(e ?OR: 3656 Q 15<1 / 9351@5 E& (,&*s*s

12



+o, re"res*, &o"!s-*+( >os-r +o>o (r*(=&es *,ee,*e,-es e (so+*(+*,+o, (>#-(+*, &( rese,+*( e (s+#&o(-!( er*r*+( "r(e ?r 25;;% 2523)@ e *,e++*, "r(e ?r 25;<% 25226;@5 ?13@

E, Es-(os U,*os e Nor-e(>r*+(% e, &( +*#( e Co&#>=*(% se &&e (

+(=o #, es-#*o or C(r&so, ' Ree% se e,+o,-r H#e (+-ores +o>o seKo>(s+#&*,o ?OR: 15 Q 15)2 / )5)<@% re-*,o(-!( *(=-*+( ?OR5 653 Q 35;6 /32522@% *,s#*+*e,+*( +(r!(+( +o,"es-*( ?OR: 35; Q 3513 / 153<@Q (=s+esose, *e ?OR: 6652 Q 3<542 / <<532@ ' os-eo>*e&*-*s ?OR: 3252 Q 42522 / 1)6522@se (so+*(ro, s*",**+(-*(>e,-e ( &( (>#-(+*, >e,or e, e& (+*e,-e +o,*e *(=-*+o5 ?1)@

E, Cos-( Ro+(% e, &( +*#( e S(, Jos% se re(&*$ #, es-#*o or L(+& 'V(&ero% e,+o,-r(ro, H#e &os (+*e,-es *(=-*+os +os-(rr*+e,ses +o, >('or ro=(=*&*( e s#r*r #,( (>#-(+*, e &( eK-re>*( *,er*or #ero, seKo

>(s+#&*,o ?OR: 35< Q 25) / 6599@% = A3+ ≥ ?OR: 3256 Q 15)9 / 6456)@%

re-*,o(-!( ?OR: ;5< Q 159) / 395)<@% -r(-(>*e,-o +o, *,s#&*,( ?OR: 3;5 Q )59 / 915<@% ' (>#-(+*, re*( ?OR: 415) Q 3)5)4 / 12654@5 ?16@

E, Br(s*&% e, &( +*#( e S(o P(#&o% se re(&*$ #, es-#*o or A,-(r G(>=(%' +o&% e>os-r(ro, &os (+-ores (so+*(os +o, (>#-(+*, e, (+*e,-es +o,*e *(=-*+o: F#>(r ?OR: 65; Q 352< / 3<542@% "&#+os( 122 >"& ?OR: ;53 Q35;4 / 115;6@% re-*,o(-!( er*r*+( ?OR: )56Q 3526 / 3352@ ' (s+#&o(-!(?OR: 335Q )569 / 62513@5 ?14@

E, Br(s*&% e, &( +*#( e S(o P(#&o% se &&e ( +(=o o-ro es-#*o or Pr(oos S(,-os% ' +o&5 e>os-r(ro, &os (+-ores (so+*(os +o, (>#-(+*,>('or e, (+*e,-es +o, *e *(=-*+o: L*,(,"*-*s (s+e,e,-e ?OR: 154@%&es*o,es e, e& +(&+,eo ?OR: 3254@% &es*o,es (",er "r(o V ?OR: )56@%*,s#*+*e,+*( (r-er*(& +r,*+( s*, os*=*&*( e re(s+#&*$(+*, ?OR: 456@5 ?1<@

E, E+#(or% e, &( +*#( e G#('(H#*&% se &&e ( +(=o #, es-#*o or C(>=(& ' P(rr(&es% se e,+o,-r H#e (+-ores +o>o "(,"re,( &o+(&*$((%?OR: *,e*,*oQ *,e*,*o@% (#se,+*( e #&sos ?OR: 31;52 Q 3456 /

3221566@% *,e++*, ?OR: 953 Q 3352 / ;4533@% +o>ro>*so eK-e,so e-e*o ?OR: 9)54 Q <5) / 49;53<@% s#s+e-*=*&*( ( *,e++*, ?OR: 1)5< Q 563 / ;523@% +e&#&*-*s or e,+*>( e& -o=*&&o ?OR: 325; Q 6534 / 19514@% re-r(so*(",s-*+o ?OR: <52 Q )52; / 1;566@% r*( e -e*os =&(,os ?OR: 5) Q)5); / 125)<@% (=s+esos &(,-(res ?OR: ;54 Q 15;; / 3;521@ ' ,e#ro(-!( ?OR:156 Q 3526 / 4566@ se (so+*(ro, s*",**+(-*(>e,-e ( -r(-(>*e,-o +o,(>#-(+*, e, e& (+*e,-e +o, *e *(=-*+o5 ?1;@

E, Per% e, &( +*#( e L*>(% e, e& os*-(& ESSALUD S(=o"(&% se ee+#-#, es-#*o or V*(&% e,+o,-r H#e e& "r(o e &es*, ?(",er@ +orre&(+*o,e, or>( *re+-( ' s*",**+(-*( +o, &( ro=(=*&*( e (>#-(+*, >('or e,(+*e,-e +o, *e *(=-*+o ?+oe*+*e,-e e Pe(rso, 2%;% 2523 K 1 W25223@5 E& (",er IV -#o &( >('or (so+*(+*, ?OR: 52 Q )531 / 1254)@5 E&

13



,*e& e (#se,+*( e #&so -#o s*",**+(,-e (so+*(+*, +o, &( ro=(=*&*(e (>#-(+*, >('or e, (+*e,-e +o, *e *(=-*+o% K1 W 25223 ?Pe(rso,25469 +o, W 25223@ s*e,o &( >('or (so+*(+*, ?OR: 95 Q )529 / 3<52@(r( (#se,+*( e #&so e*o ' -*=*(& os-er*or5 ?3@

E, Per% e, &( +*#( e Tr#*&&o% e, e& os*-(& ESSALUD V!+-or L($(r-eE+e"(r(' se ee+#- #, es-#*o or EsH#*e&% se e,+o,-r H#e (+-ores+o>o -*e>o e eo&#+*, e DM1 >('or e 32 (os ?OR: ;56 Q 152 /36562@% >(& +o,-ro& e &( "&*+e>*( ?OR: )59 Q 35;6 / 536@% *er-e,s*, (r-er*(&?OR: 953 Q 154 / 39562@ ' *s&**e>*( ?OR: 153 Q 3521 / 6566@ +o,s-*-#'e,(+-ores e r*es"o e, &( (>#-(+*, >('or e (+*e,-es +o, *e *(=-*+o5?)2@

%. AMPUTACIÓN EN EL PIE DIABÉTICO

L( (>#-(+*, es e& &-*>o re+#rso (r( e*-(r &( +o>&*+(+*, o >#er-e e&(+*e,-e +o, PD5 To( (>#-(+*, H#e se re(&*$( e, e& *e se e,o>*,(>e,or ' &(s H#e se re(&*$(, or (rr*=( e& -o=*&&o% *,+&#'e,o &( *,r(+o,!&e(' s#r(+o,!&e(% se e,o>*,(, >('ores5 Es reer*=&e #,( (>#-(+*,>e,or orH#e +o, es-( e& (+*e,-e +(s* s*e>re #ee +(>*,(r or s! so&o5C#(,o es (>#-(+*, >('or% e& (+*e,-e e=er #s(r e, or>( er>(,e,-e#,( >#&e-(% r-es*s o s*&&( e r#e(s s* H#*ere es&($(rse5?36@Se *,*+( (>#-(+*, >('or +#(,o #, >*e>=ro *sH#>*+o ,o se #eere(s+#&(r*$(r o es (e+-(o or os-eo>*e&*-*s *#s( H#e ,o reso,e (&-r(-(>*e,-o ' (>e,($( &( *( e& (+*e,-e5?36@C#(,o e& >*e>=ro *,e+-(o +o,s-*-#'e #, o+o s-*+o H#e ,o reso,e (&-r(-(>*e,-o (,-*=*-*+o ' es=r*(>*e,-os% (r( s(&(r &( *( e& (+*e,-e see=e -o>(r &( e+*s*, e #,( (>#-(+*, >('or5?36@P#ee, s#r*r (>#-(+*o,es +o,se+#-*(s e, e& >*s>o >*e>=ro o e, e&>*e>=ro +o&(-er(&% ' +o, #, ro,s-*+o o=re ( &(r"o &($o% +o, #,( -(s( e&e-(&*( ( &os ) (os e,-re )4 ' 42 ' #,( -(s( (+#>#&(-*( ere(>#-(+*, e,-re )2 ' ;2 es#s e 3 ) (os5 ?6% @

&. CONCLUSIONES

•

Les*o,es e, e& +(&+,eo% &es*o,es (",er "r(o V% *,s#*+*e,+*( (r-er*(&+r,*+( s*, os*=*&*(es e re(s+#&(r*$(+*, so, (+-ores e r*es"o e, &('()*+',-/ ('0 e (+*e,-es +o, *e *(=-*+o% se", e& es-#*o>e,+*o,(o5 ?1<@

• Re-*,o(-!( *(=-*+(% (=s+esos e, *e% os-eo>*e&*-*s so, (+-ores er*es"o e, &( '()*+',-/ (/ e (+*e,-es +o, *e *(=-*+o% se", e&es-#*o >e,+*o,(o5 ?1)@

• A&-o "r(o e &( +&(s**+(+*, e (",er ? ≥ "r(o )@% seKo e>e,*,o%

>o,*-or*$(+*, e &os ,*e&es e =AI+ >e,os e os e+es or (o%e,er>e( (r-er*(& er*r*+(s% =AI+ 954% (s+#&o(-!( er*r*+(

14



"r(e% *,e++*, "r(e% re-*,o(-!( *(=-*+(% -r(-(>*e,-o +o, *,s#&*,(%(>#-(+*, re*(% "&#+os( 122 >"&% "(,"re,( &o+(&*$((% (#se,+*(e #&sos e, >*e>=ros *,er*ores% +o>ro>*so eK-e,so e -e*o%s#s+e-*=*&*( ( *,e++*,% +e&#&*-*s or e,+*>( e& -o=*&&o% re-r(so*(",s-*+o% r*( e -e*os =&(,os% so, (+-ores e r*es"o e, &(

'()*+',-/ e (+*e,-es +o, *e *(=-*+o% se", &os es-#*os>e,+*o,(os5 ?13% 11% 16% 14% 1;% 19% 1@

• Gr(o e &es*, ?(",er@% ,*e& e (#se,+*( e& #&so (r-er*(& e,>*e>=ros *,er*ores% -*e>o e eo&#+*, e DM1 >('or e 32 (os%*er-e,s*, (r-er*(&% so, (+-ores e r*es"o e, &( '()*+',-/ ('0 e&(+*e,-e +o, *e *(=-*+o e, e& Per% se", &os es-#*os >e,+*o,(os5?3% )2@

• Les*o,es e, e& +(&+,eo *,+re>e,-( e& r*es"o e (e+er '()*+',-/('0 e, (+*e,-es +o, *e *(=-*+o e, 3254 e+es >s e, +o>(r(+*,+o, (+*e,-es +o, *e *(=-*+o H#e ,o rese,-(, &es*o,es e, e& +(&+,eo5?1<@

• Les*o,es (",er "r(o V *,+re>e,-( e& r*e"o e (e+er '()*+',-/('0 e, (+*e,-es +o, *e *(=-*+o e, )56 e+es >s e, +o>(r(+*,+o, (+*e,-es +o, *e *(=-*+o H#e ,o rese,-(, &es*o,es (",er "r(oV5 ?1<@

•

I,s#*+*e,+*( (r-er*(& +r,*+( s*, os*=*&*( e re(s+#&(r*$(+*,*,+re>e,-( e& r*es"o e (e+er '()*+',-/ ('0 e, (+*e,-es +o, *e*(=-*+o e, 456 e+es >s e, +o>(r(+*, +o, (+*e,-es +o, *e*(=-*+o s*, *,s#*+*e,+*( (r-er*(& +r,*+( s*, os*=*&*( ere(s+#&(r*$(+*,5 ?1<@

• Re-*,o(-!( *(=-*+( *,+re>e,-( e& r*es"o e (e+er '()*+',-/(/ e, (+*e,-es +o, *e *(=-*+o e, 6535 e+es >s e, +o>(r(+*,+o, (+*e,-es +o, *e *(=-*+o s*, re-*,o(-!( *(=-*+(5 ?1)@

• A=s+esos e, *e *,+re>e,-( e& r*es"o e (e+er '()*+',-/ (/ e,(+*e,-es +o, *e *(=-*+o e, 6652 e+es >s e, +o>(r(+*, +o,(+*e,-es +o, *e *(=-*+o H#e ,o rese,-(, (=s+esos e, *e5 ?1)@

• Os-eo>*e&*-*s *,+re>e,-( e& r*es"o e (e+er '()*+',-/ (/ e,(+*e,-es +o, *e *(=-*+o e, 3252 e+es >s e, +o>(r(+*, +o,(+*e,-es +o, *e *(=-*+o H#e ,o rese,-(, os-eo>*e&*-*s5 ?1)@

• A&-o "r(o e &( +&(s**+(+*, e (",er ? ≥ )@ *,+re>e,-( e& r*es"o e

(e+er '()*+',-/ e, (+*e,-es +o, *e *(=-*+o e, 3)53 e+es >se, +o>(r(+*, +o, (+*e,-es +o, *e *(=-*+o H#e rese,-(,+&(s**+(+*, e (",er W )5 ?19@

15



• SeKo e>e,*,o *,+re>e,-( e& r*es"o e (e+er '()*+',-/ e,(+*e,-es +o, *e *(=-*+o e, 59 e+es >s e, +o>(r(+*, +o,(+*e,-es +o, *e *(=-*+o e seKo >(s+#&*,o5 ?11@

• Mo,*-or*$(+*, e &os ,*e&es e =A3+ >e,os e 1 e+es or (o

*,+re>e,-( e& r*es"o e (e+er '()*+',-/ e, (+*e,-es +o, *e*(=-*+o e, 3)5< e+es >s e, +o>(r(+*, +o, (+*e,-es +o, *e*(=-*+o H#e >o,*-or*$(, &os ,*e&es e =A3+ 1 >s e+es or (o5?11@

• E,er>e( (r-er*(& er*r*+( *,+re>e,-( e& r*es"o e (e+er '()*+',-/ e, (+*e,-es +o, *e *(=-*+o e, 4535 e+es >s e,+o>(r(+*, +o, (+*e,-es +o, *e *(=-*+o H#e ,o rese,-(,e,er>e( (r-er*(& er*r*+(5 ?1@

•

N*e& e e>o"&o=*,( "&#+os*&(( or e,+*>( e 954 *,+re>e,-( e&r*es"o e (e+er '()*+',-/ e, (+*e,-es +o, *e *(=-*+o e, 1252e+es >s e, +o>(r(+*, +o, (+*e,-es +o, *e *(=-*+o H#erese,-(, e>o"&o=*,( "&#+os*&(( or e=(o e 9545 ?1@

• Prese,+*( e (s+#&o(-!( er*r*+( "r(e *,+re>e,-( e& r*es"o e(e+er '()*+',-/ e, (+*e,-es +o, *e *(=-*+o e, 9535 e+es >s e,+o>(r(+*, +o, (+*e,-es +o, *e *(=-*+o s*, (s+#&o(-!( er*r*+("r(e5 ?13@

• I,e++*, "r(e *,+re>e,-( e& r*es"o e (e+er '()*+',-/ e,

(+*e,-es +o, *e *(=-*+o e, 3656 e+es >s e, +o>(r(+*, +o,(+*e,-es +o, *e *(=-*+o H#e ,o rese,-(, *,e++*, "r(e5 ?13@

• Re-*,o(-!( *(=-*+( *,+re>e,-( e& r*es"o e (e+er '()*+',-/ e,(+*e,-es +o, *e *(=-*+o e, ;5< e+es >s e, +o>(r(+*, +o,(+*e,-es +o, *e *(=-*+o H#e ,o rese,-(, re-*,o(-!( *(=-*+(5 ?16@

• Tr(-(>*e,-o +o, *,s#&*,( *,+re>e,-( e& r*es"o e (e+er '()*+',-/ e,(+*e,-es +o, *e *(=-*+o e, 3;5 e+es >s e, +o>(r(+*, +o,(+*e,-es +o, *e *(=-*+o s*, -r(-(>*e,-o +o, *,s#&*,(5 ?16@

• A>#-(+*, re*( *,+re>e,-( e& r*es"o e (e+er '()*+',-/ e,(+*e,-es +o, *e *(=-*+o e, 415) e+es >s e, +o>(r(+*, +o,(+*e,-es +o, *e *(=-*+o s*, es-e (,-e+ee,-e5 ?16@

• G&#+os( 122 >"& *,+re>e,-( e& r*es"o e (e+er '()*+',-/ e,(+*e,-es +o, *e *(=-*+o e, ;535 e+es >s e, +o>(r(+*, +o,

(+*e,-es +o, *e *(=-*+o +o, "&#+os(s ≤ 122 >"&5 ?14@

• G(,"re,( &o+(&*$(( *,+re>e,-( e& r*es"o e (e+er '()*+',-/ e,

(+*e,-es +o, *e *(=-*+o e, or>( *,e*,*( e, +o>(r(+*, +o,(+*e,-es +o, *e *(=-*+o H#e ,o rese,-(, "(,"re,( &o+(&*$((5 ?1;@

16



• A#se,+*( e #&so e, >*e>=ros *,er*ores *,+re>e,-( e& r*es"o e(e+er '()*+',-/ e, (+*e,-es +o, *e *(=-*+o e, 31; e+es >s e,+o>(r(+*, +o, (+*e,-es +o, *e *(=-*+o H#e rese,-(, #&sos e,>*e>=ros *,er*ores5 ?1;@

• Co>ro>*so eK-e,so e -e*o *,+re>e,-( e& r*es"o e (e+er '()*+',-/ e, (+*e,-es +o, *e *(=-*+o e, 9)54 e+es >s e,+o>(r(+*, +o, (+*e,-es +o, *e *(=-*+o s*, +o>ro>*so eK-e,so e-e*o5 ?1;@

• S#s+e-*=*&*( ( *,e++*, *,+re>e,-( e& r*es"o e (e+er '()*+',-/e, (+*e,-es +o, *e *(=-*+o e, 1)5< e+es >s e, +o>(r(+*, +o,(+*e,-es +o, *e *(=-*+o H#e ,o rese,-(, s#s+e-*=*&*( ( *,e++*,5?1;@

• Ce&#&*-*s or e,+*>( e -o=*&&o *,+re>e,-( e& r*es"o e (e+er '()*+',-/ e, (+*e,-es +o, *e *(=-*+o e, 325; e+es >s e,+o>(r(+*, +o, (+*e,-es +o, *e *(=-*+o H#e ,o rese,-(, +e&#&*-*sor e,+*>( e -o=*&&o5 ?1;@

• Re-r(so *(",s-*+o *,+re>e,-( e& r*es"o e (e+er '()*+',-/ e,(+*e,-es +o, *e *(=-*+o e, <52 e+es >s e, +o>(r(+*, +o,(+*e,-es +o, *e *(=-*+o +o, *(",s-*+o oor-#,o5 ?1;@

• Pr*( e -e*os =&(,os *,+re>e,-( e& r*es"o e (e+er '()*+',-/

e, (+*e,-es +o, *e *(=-*+o e, 5) e+es >s e, +o>(r(+*, +o,(+*e,-es +o, *e *(=-*+o s*, r*( e -e*os =&(,os5 ?1;@

• E& "r(o e &es*, (",er IV *,+re>e,-( e& r*es"o e (e+er '()*+',-/ e, (+*e,-es +o, *e *(=-*+o e, 52 e+es >s e,+o>(r(+*, +o, (+*e,-es +o, *e *(=-*+o H#e ,o rese,-(, *+o"r(o e &es*,5 ?3@

• A#se,+*( e #&so e*o ' -*=*(& os-er*or *,+re>e,-( e& r*es"o e (e+er '()*+',-/ ('0 e, (+*e,-es +o, *e *(=-*+o e, 95 e+es >s e,

+o>(r(+*, +o, (+*e,-es +o, *e *(=-*+o H#e rese,-(, #&so e*o '-*=*(& os-er*or5 ?3@

• T*e>o e eo&#+*, e DM1 >('or e 32 (os *,+re>e,-( e& r*es"o e(e+er '()*+',-/ ('0 e, (+*e,-es +o, *e *(=-*+o e, ;56 e+es>s e, +o>(r(+*, +o, (+*e,-es +o, *e *(=-*+o +o, -*e>o eeo&#+*, e DM1 >e,or e 32 (os5 ?)2@

• *er-e,s*, (r-er*(& *,+re>e,-( e& r*es"o e (e+er '()*+',-/ ('0 e, (+*e,-es +o, *e *(=-*+o e, 953 e+es >s e, +o>(r(+*, +o,(+*e,-es +o, *e *(=-*+o +o, res*, (r-er*(& ,or>(&5 ?)2@

17



. RECOMENDACIONES

• Se e=e re(&*$(r #,( *s-or*( +&!,*+( >*,#+*os(% (s! +o>o &os eK>e,ese &(=or(-or*o er-*,e,-es H#e er>*-(, *e,-**+(r (+-ores e r*es"o e(>#-(+*, e, (+*e,-es +o, *e *(=-*+o% +o, e& *, e #, >(,eo

(e+#(o e es-os% er>*-*e,o re#+*r &( -(s( e (>#-(+*o,es5

• Se s#"*ere &( re(&*$(+*, e >s es-#*os e, ,#es-ro (!s (+er+( e &os(+-ores e r*es"o e (>#-(+*, e, *e *(=-*+o (r( +o,o+er &(s*-#(+*, (+-#(&% ( *, e -o>(r +o,+*e,+*( ' re(&*$(r (+-**(esree,-*(s ' e +o,-ro&5

• E& "r#o s(,*-(r*o *>&*+(os e, &( (-e,+*, e (+*e,-es +o, *e *(=-*+oe=e ser (*5+-6-7,-)5-/'- ?#,*( e #r"e,+*(s% +*r#(,os "e,er(&es 'o(s+#&(res% e,o+r*,&o"o% re(=*&*-(ores5 R(*&o"os% e,er>eros%

*s*o-er(e#-(s% o&o"o% e-+5@ +*r+#,s-(,+*( H#e #ee +o,*+*o,(r #,(&-o "r(o e (r*(=*&*( +&!,*+( e, s# >(,eo5

P(r( er>*-*r #, >eor >(,eo e &os (+*e,-es +o, *e *(=-*+o% +o, e&*, e ree,*r o *s>*,#*r &( -(s( e (>#-(+*, e, *e *(=-*+o ' ees-( >(,er( =r*,(r #,( >eor +(&*( e *( ( *+os (+*e,-es se (+e,e+es(r*o H#e -oos &os os*-(&es e& Per +#e,-e, +o, &( UNIDAD DELPIE DIABÉTICO.

18.REFERENCAS BIBLIOGRÁFICAS

35 V*(& G% Do>!,"#e$ A5 F(+-ores e r*es"o e (>#-(+*, e, e& *e*(=-*+o5 ReSo+ Per Me I,-er,( 1232Q 1) ?6@: 364 36<5

15 Torres % G#-*erre$ C% P(#e&o J% P(,o R% Ar=(*& 5 C(r(+-er!s-*+(s+&!,*+(s ' e*e>*o&"*+(s e &os (+*e,-es os*-(&*$(os or *e*(=-*+o e, e& os*-(& N(+*o,(& Dos e M('o e,-re 122; ' 122% L*>( Per5 REV Per# E*e>*o& 1231Q 3; ?)@: 3 ;5

)5 L*sX' B% Bere,- A% Cor,*( P% P*&e J5 1231 I,e+-*o#s D*se(ses So+*e-' o A>er*+( C&*,*+(& Pr(+-*+e G#*e L*,e or -e D*(",os*s (, -re(->e,- o

D*(=e-*+ Foo- I,e+-*o,s5 C&*,*+(&I,e+-*o#sD*se(ses 1231Q 46 ?31@: 3)1 /39)5

65 Es+(&(,-e D% Le++( L% G(>(rr( J% Es+(&(,-e G5 A>#-(+*, e& >*e>=ro*,er*or or *e *(=-*+o e, os*-(&es e &( Cos-( Nor-e Per#(,( 3<<2/1222: C(r(+-er!s-*+(s C&!,*+o / E*e>*o&"*+(s5 Re Per >eeK s(&#=&*+( 122)Q 12 ?)@: 3) 3665

45 Ro>ero J% er,,e$ J% To(r A% Mo,-*e& M5 Mor=*&*(es e (+*e,-es+o, *e *(=-*+o *,"res(os (& ser*+*o e +*r#"!( e& os*-(&U,*ers*-(r*o “Dr A&reo V(, Gr*e e,”5 ReVe,e$C*r 1229Q ;2 ?3@: 13 1;5

18



;5 Ir*=(rre, O% P(ss* G% A'=(r N% R*os P5 P*e *(=-*+o: E(&#(+*, e, #,(ser*e e 313 (+*e,-es5 Re C*&e,( e C*r#"!( 1229Q 44 ?4@: ))9 )635

95 G(r+!( E5 P*e *(=-*+o5 Re*s-( e E,o+r*,o&o"!( ' ,#-r*+*, 1221Q 32?1@: 65

5 M(r-!,e$ D5 Tr(-(>*e,-o e &( *,e++*, e, e& *e *(=-*+o5 C*rEs 1226Q9; ?3@: < 345

<5 C#e( V% Me!( J% L#e,"(s % S(&*,(s O5 Co>&*+(+*o,es e& *e*(=-*+o5 F(+-ores e r*es"o (so+*(os5 Re>e IMSS 122)Q 63 ?1@: <93265

325M(r-!,e$ D% A"#('o J% Mor(&es G% A"#*r, L% I&&, F5 I>(+-o e #,("#!( +&!,*+( (r( e& *e *(=-*+o e, #, os*-(& "e,er(&5 A,Me I,-er,(1226Q 13 ?<@: 612 6165

335 Sor*(,o J% Re'es C% F("o("( J5 V(&or -er(#-*+o e &( oK*"e,(+*,*er=r*+( e, e& *e *(=-*+o *,e+-(o5 Re S,*M*&*-MeK 1226Q 4?3@: 32/365

315L*# R% L* L% Y(," M% Boe, G5 S's-e>(-*+ Re*e o -e Ee+-*e,esso 'er=(r*+ OK'"e,(-*o, -er(' *, -e >(,("e>e,- o Cro,*+D*(=e-*+ Foo- U&+ers5 M('o C&*,Pro+ 123)Q ?1@: 3;; / 3945

3)5V*r(>o,-es G% E,r!H#e$ R% Le$ G% Serr(,o R5 (&&($"os(,"*o"r*+os e, (+*e,-es +o, *e *(=-*+o5 A,(&es e R(*o&o"!(MK*+o 122;Q 1 ?3@: 32</33;5

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