10 research outputs found
Pancreatic pseudocyst eroding into the splenoportal venous confluence and mimicking an arterial aneurysm
No full textWe report the case of a 62-year-old man with chronic pancreatitis who presented with increasing abdominal pain. Sonography, magnetic resonance imaging, contrast-enhanced computed tomography, and ultimately catheter angiography demonstrated a pancreatic pseudocyst that had eroded into the splenoportal venous confluence, mimicking an arterial aneurysm. The diagnostic was confirmed at the time of surgical treatment. This case demonstrates the use of imaging to diagnose complications of pancreatitis, and the difficulty of distinguishing an eroding pseudocyst from an arterial aneurysm
Superparamagnetic Iron Oxide (SPIO)-enhanced Liver MR Imaging with Ferucarbotran
No full textDie Superparamagnetic Iron Oxides (SPIO)-verstärkte MRT der Leber wird als sinnvolle präoperative diagnostische Methode mit einer hohen Sensitivität und Spezifität für die Detektion von fokalen Leberläsionen angewendet. Mit der SPIO-verstärkten MRT ist aber prinzipiell auch eine Differenzierung zwischen benignen und malignen fokalen Leberläsionen möglich auf der Basis ihrer zellulären Zusammensetzung und Funktion (RES-Zellen in normalem Lebergewebe und in benignen Tumoren, keine RES-Zellen in malignen Tumoren).
In früheren Studien wurden die Effekte von SPIO-Kontrastmitteln fast ausschließlich auf die Detektion von Läsionen sowie die Effekte in T2-gewichteten (w) Fast-Spin Echo (FSE) und T2*-w Gradienten Echo (GRE) Sequenzen beschränkt, da SPIO hauptsächlich die T2 / T2* - Zeiten verkürzen.
Ferucarbotran ist ein relativ neu zugelassenes SPIO-Kontrastmittel, welches als intravenöser Bolus appliziert werden kann und sich durch eine geringe Nebenwirkungsrate vor allem im kardiovaskulären Bereich auszeichnet. Eine dynamische T1-w Perfusionsmessung nach der Bolusapplikation von Ferucarbotran könnte Informationen über die Vaskularisation solider Tumore in der Leber liefern. Die Möglichkeit der Charakterisierung von fokalen Leberläsionen mit Hilfe der dynamischen Ferucarbotran-verstärkten MRT wurde bereits in der Literatur angedeutet und typische Befunde konnten an einer begrenzten Anzahl von Fällen für einzelne fokale Leberläsionen gezeigt werden.
Das erste Ziel dieser Arbeit war die Evaluierung der diagnostischen Effizienz des SPIO Kontrastmittel Ferucarbotran in T2-w FSE and T2*-w GRE Sequenzen zur Charakterisierung von fokalen Leberläsionen. Das zweite Ziel war es typische Anreicherungsmuster fokaler Leberläsionen in der dynamischen T1-w MRT mit 2D-GRE and 3D-GRE VIBE Sequenzen zu beschreiben.
An einem 1.5 Tesla MRT-System wurden native und kontrastverstärkte T2-w FSE and T2*-w GRE Sequenzen 10 Minuten nach Bolusinjektion von 1.4 ml Ferucarbotran bei 68 Patienten durchgeführt. An einem 1.5 Tesla MRT-System wurden T1-w dynamische Bilder bei 23 Patienten mit einer 2D-GRE Sequenz und bei 37 Patienten mit einer 3D-GRE-VIBE Sequenz akquiriert.
Die endgültige Diagnose der 68 Patienten, bei denen T2-w FSE/ T2*-w GRE Sequenzen durchgeführt wurden war Hepatozelluläres Karzinom (HCC, n=29), Lebermetastasen (n=15), Cholangiozelluläres Karzinom (CCC, n=2), Hämangiom (n=6), Leberzelladenom (n=5), Fokal Noduläre Hyperplasie (FNH, n=3) und Zysten (n=8). Die endgültige Diagnose der 60 Patienten, bei denen eine T1-w dynamische Ferucarbotran-verstärkte MRT durchgeführt wurde war HCC (n=25), Lebermetastasen (n=14), CCC (n=2), Hämangiom (n=6), Leberzelladenom (n=3), FNH (n=3) and Zysten (n=7). In den T2-w FSE und T2*-w GRE Bildern wurde das Signal-zu-Rausch-Verhältnis (SNR) und das Kontrast-zu-Rausch-Verhältnis basierend auf Signalintensitätsmessungen in den fokalen Läsionen und dem Leberparenchym durchgeführt. Der prozentuale Signalverlust (PSIL) der verschiedenen fokalen Läsionen von der nativen zur kontrastverstärkten T2-w FSE –Sequenz wurde errechnet. Eine qualitative Auswertung der Bildqualität sowie der Abgrenzbarkeit der Läsionen im Vergleich zwischen kontrastverstärkten T2-w FSE und kontrastverstärkten T2*-w GRE Bildern erfolgte. In den T1-w dynamischen Bildern wurden Signalintensitätsmessungen im Leberparenchym, den Lebergefäßen und in fokalen Leberläsionen vorgenommen um SNR und CNR zu errechnen.
Das mittlere SNR von soliden benignen Läsionen zeigte einen Abfall in der T2-w FSE Sequenz von 34.1 vor auf 21.0 (p<0,05) nach Kontrastmittelgabe; maligne Leberläsionen zeigten nur einen geringen Signalverlust von 33.3 auf 32.5 (nicht signifikant). Das mittlere CNR der malignen Läsionen war am höchsten in der kontrastverstärkten T2*-w Sequenz vergleichen mit der nativen- und kontrastverstärkten T2-w FSE Sequenz (29.9 vs. 22.7 (p<0.01) vs. 12.8 SI (p<0.01)). Bei einem Grenzwert von 25 % Signalverlust (PSIL) in der T2-w FSE Sequenz konnte eine Sensitivität und Spezifität von 97.8% beziehungsweise 92.9% mit der Ferucarbotran-verstärkten T2-w MRT erreicht werden. Der Signalverlust (PSIL) von Adenomen und FNH zeigte keine Überschneidungen. Kontrastverstärkte T2*-w GRE Bilder zeichneten sich durch eine überlegene Bildqualität und Abgrenzbarkeit von Läsionen (p < .05) im Vergleich zur kontrastverstärkten T2-w FSE Sequenz aus. In der dynamischen Ferucarbotran-verstärkten T1-w MRT konnte eine Hypervaskularisation in den typischerweise hypervaskularisierten Läsionen wie HCC, Adenom oder FNH nicht gezeigt werden. In Hämangiomen hingegen war ein frühes Enhancement in allen Fällen abzugrenzen. In der T1-w 3D-GRE Sequenz lag das mittlere CNR der soliden benignen Läsionen bei etwa null (FNH) oder war sogar positiv (Adenom), während das mittlere CNR der malignen Läsionen im negativen Bereich zu allen Zeitpunkten lag.
Zusammenfassend konnte gezeigt werden, dass solide benigne Läsionen eine SPIO-Speicherung zeigen, welche einen signifikanten Signalabfall in den Läsionen in T2-w Bildern hervorruft. Mit einem Grenzwert von 25% Signalverlust (PSIL) kann eine sichere Unterscheidung von benignen und malignen Läsionen erfolgen. Für die Detektion von Läsionen ist eine zusätzliche T2*-w Sequenz hilfreich wegen des stärkeren Läsion-zu-Leber-Kontrastes (CNR), einer verbesserten subjektiven Abgrenzbarkeit der Läsionen und der besseren Bildqualität. Mit der dynamischen T1-w MRT mit einer 3D-GRE Sequenz nach Bolusinjektion von Ferucarbotran können möglicherweise Aspekte zur Charakterisierung von malignen versus benignen Leberläsionen gewonnen werden. Allerdings liefert die T1-w dynamische MRT offensichtlich weder mit 2D- noch mit 3D-GRE Sequenzen die gleiche Information über die Vaskularisation von Leberläsionen wie die Gadolinium-verstärkte MRT, da die von den extrazellulären Kontrastmitteln bekannten Anreicherungsphänomene in hypervaskularisierten Leberläsionen mit der dynamischen Ferucarbotran-verstärkten MRT nicht nachvollzogen werden konnten. Für die Praxis bedeutet dies, dass der Schwerpunkt der Ferucarbotran-verstärkten MRT Untersuchung weiterhin bei den T2-w und T2*-w Sequenzen liegt, um die in der Literatur berichteten hohen Detektionsraten und die von uns untersuchten Möglichkeiten zur Charakterisierung auszunutzen. Die während der Bolusapplikation durchgeführte T1-w dynamische Bildgebung kann in limitierten Fällen wie z.B. Häma-ngiomen differentialdiagnostische Hilfestellungen liefern, kann aber die Information einer dynamischen Untersuchung mit extrazellulären Kontrastmitteln nicht ersetzten
Molecular imaging using positron emission tomography in gastrointestinal malignancy
No full textPositron Emission Tomography (PET) with 18F-FDG has emerged as a powerful tool in oncology. Furthermore, recent advent of PET/CT and novel tracers are continually expanding its role. This thesis investigates its application in two solid cancer models.
In the diagnosing of primary pancreatic cancer, 18F-FDG PET/CT was shown to be more accurate than conventional CT. It did not add information to locoregional staging of disease but impacted management of patients with potentially operable tumours, by accurately confirming the presence / absence of metastases. In the pre-operative staging of patients with colorectal liver metastases (CLM), 18F- FDG PET/CT was also superior to CT in assessing extrahepatic disease, where it again impacted management. The accuracy of detecting hepatic disease was similar for both. Compared to PET alone, PET/CT improved the accuracy of lesions localization and interpretation.
Next, the feasibility of imaging with the novel thymidine analogue tracer 18F-FLT was investigated. Overall, 18F-FLT PET was less accurate than 18F-FDG in detecting lesions in both cancer types, thus suggesting it to be an unsuitable tracer for routine diagnosis and staging. In the cohort of pancreatic cancer patients, 18F-FLT uptake (SUVs) were found to strongly correlate with the immunohistochemical proliferation marker, Ki-67 antigen. This supported 18F-FLT‟s potential role as a surrogate marker of proliferation. The prognostic implications of these require further investigation.
Finally, an in vitro model was use to examine early changes in 18F-FLT uptake in response to treatment with cytotoxics. At 2 hours following pulse treatment with 5-fluorouracil, (and before changes in cell numbers and cell cycle phase were seen), a dose dependent increase in 18F-FLT uptake was seen. No change was observed with 18F-FDG nor following Cisplatin treatment. This adaptive response may have a role as an early predictor of response to 5-FU (and potentially other antimetabolites), which requires further investigation
An investigation into the mechanical and biological properties of acrylic bone cement containing triphenyl bismuth (TPB) as an alternative radiopacifier
No full textPhDTotal joint replacement is the most successful method of treating end-stage
arthritis. It significantly improves the quality of life and the functional capability
of patients suffering from arthritis. Currently an estimated 40,000 total joint
arthroplasties are performed each year in the United Kingdom, and over 42% of
these are performed in patients younger than 65 years.
Poly(methylmethacrylate) bone cement is used to fill the space between the bone
and the prosthesis in joint replacements and thus forms a mechanical bond
between the two surfaces. The cement layer transfers the load from the prosthesis
to the bone and increases the load bearing capacity of the implant-cement-bone
system.
Surgeons require bone cement to be radiopaque on radiographs in order to
monitor the position of the implant after a joint replacement surgery. Therefore
heavy metal salts such as barium sulphate and zirconium dioxide are added to
bone cement to impart such radiopacity. The addition of these radiopacifiers,
however, degrades the mechanical properties of the bone cement due to the lack
of chemical bonding between the radiopacifier and the polymer matrix. Barium
sulphate is known to adversely affect the mechanical strength and fracture
toughness of bone cement. Various studies have also shown that barium sulphate
and zirconium dioxide may contribute to the pathological bone resorption of
aseptic loosening by enhancing macrophage-osteoclast differentiation. In this
study an organo-bismuth compound, triphenyl bismuth (TPB) has been
investigated as a potential radiopaque alternative to barium sulphate in bone
cements. The inclusion of TPB has been shown to improve the mechanical
properties of bone cement including fracture toughness. Furthermore, it has also
been shown to cause less bone resorption, which is usually associated with
aseptic loosening in joint replacement
Describing Peripancreatic Collections According to the Revised Atlanta Classification of Acute Pancreatitis: An International Interobserver Agreement Study
No full text\ua9 2017 Wolters Kluwer Health, Inc. All rights reserved.Objectives Severe acute pancreatitis is associated with peripancreatic morphologic changes as seen on imaging. Uniform communication regarding these morphologic findings is crucial for accurate diagnosis and treatment. For the original 1992 Atlanta classification, interobserver agreement is poor. We hypothesized that for the revised Atlanta classification, interobserver agreement will be better. Methods An international, interobserver agreement study was performed among expert and nonexpert radiologists (n = 14), surgeons (n = 15), and gastroenterologists (n = 8). Representative computed tomographies of all stages of acute pancreatitis were selected from 55 patients and were assessed according to the revised Atlanta classification. The interobserver agreement was calculated among all reviewers and subgroups, that is, expert and nonexpert reviewers; interobserver agreement was defined as poor (≤0.20), fair (0.21-0.40), moderate (0.41-0.60), good (0.61-0.80), or very good (0.81-1.00). Results Interobserver agreement among all reviewers was good (0.75 [standard deviation, 0.21]) for describing the type of acute pancreatitis and good (0.62 [standard deviation, 0.19]) for the type of peripancreatic collection. Expert radiologists showed the best and nonexpert clinicians the lowest interobserver agreement. Conclusions Interobserver agreement was good for the revised Atlanta classification, supporting the importance for widespread adaption of this revised classification for clinical and research communications
Describing Peripancreatic Collections in Severe Acute Pancreatitis Using Morphologic Terms: An International Interobserver Agreement Study
No full textBackground/Aims: The current terminology for describing peripancreatic collections in acute pancreatitis (AP) derived from the Atlanta Symposium (e. g. pseudocyst, pancreatic abscess) has shown a very poor interobserver agreement, creating the potential for patient mismanagement. A study was undertaken to determine the interobserver agreement for a new set of morphologic terms to describe peripancreatic collections in AP. Methods: An international, interobserver agreement study was performed: 7 gastrointestinal surgeons, 2 gastroenterologists and 8 radiologists in 3 US and 5 European tertiary referral hospitals independently evaluated 55 computed tomography (CT) scans of patients with predicted severe AP. The percentage agreement [median, interquartile range (IQR)] for 9 clinically relevant morphologic terms was calculated among all reviewers, and separately among radiologists and clinicians. The percentage agreement was defined as poor (< 0.50), moderate (0.51-0.70), good (0.71-0.90), and excellent (0.91-1.00). Results: Overall agreement was good to excellent for the terms collection (percentage agreement = 1; IQR 0.68-1), relation with pancreas (1; 0.68-1), content (0.88; 0.87-1), shape (1; 0.78-1), mass effect (0.78; 0.62-1), loculated gas bubbles (1; 1-1), and air-fluid levels (1; 1-1). Overall agreement was moderate for extent of pancreatic nonenhancement (0.60; 0.46-0.88) and encapsulation (0.56; 0.48-0.69). The percentage agreement was greater among radiologists than clinicians for extent of pancreatic nonenhancement (0.75 vs. 0.57, p = 0.008), encapsulation (0.67 vs. 0.46, p = 0.001), and content (1 vs. 0.78, p = 0.008). Conclusion: Interobserver agreement for the new set of morphologic terms to describe peripancreatic collections in AP is good to excellent. Therefore, we recommend that current clinically based definitions for CT findings in AP (e. g. pancreatic abscess) should no longer be used. Copyright (C) 2008 S. Karger AG, Basel and IA
Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus
No full textItem does not contain fulltextBACKGROUND AND OBJECTIVE: The Atlanta classification of acute pancreatitis enabled standardised reporting of research and aided communication between clinicians. Deficiencies identified and improved understanding of the disease make a revision necessary. METHODS: A web-based consultation was undertaken in 2007 to ensure wide participation of pancreatologists. After an initial meeting, the Working Group sent a draft document to 11 national and international pancreatic associations. This working draft was forwarded to all members. Revisions were made in response to comments, and the web-based consultation was repeated three times. The final consensus was reviewed, and only statements based on published evidence were retained. RESULTS: The revised classification of acute pancreatitis identified two phases of the disease: early and late. Severity is classified as mild, moderate or severe. Mild acute pancreatitis, the most common form, has no organ failure, local or systemic complications and usually resolves in the first week. Moderately severe acute pancreatitis is defined by the presence of transient organ failure, local complications or exacerbation of co-morbid disease. Severe acute pancreatitis is defined by persistent organ failure, that is, organ failure >48 h. Local complications are peripancreatic fluid collections, pancreatic and peripancreatic necrosis (sterile or infected), pseudocyst and walled-off necrosis (sterile or infected). We present a standardised template for reporting CT images. CONCLUSIONS: This international, web-based consensus provides clear definitions to classify acute pancreatitis using easily identified clinical and radiologic criteria. The wide consultation among pancreatologists to reach this consensus should encourage widespread adoption
Describing Peripancreatic Collections According to the Revised Atlanta Classification of Acute Pancreatitis: An International Interobserver Agreement Study
No full textItem does not contain fulltextOBJECTIVES: Severe acute pancreatitis is associated with peripancreatic morphologic changes as seen on imaging. Uniform communication regarding these morphologic findings is crucial for accurate diagnosis and treatment. For the original 1992 Atlanta classification, interobserver agreement is poor. We hypothesized that for the revised Atlanta classification, interobserver agreement will be better. METHODS: An international, interobserver agreement study was performed among expert and nonexpert radiologists (n = 14), surgeons (n = 15), and gastroenterologists (n = 8). Representative computed tomographies of all stages of acute pancreatitis were selected from 55 patients and were assessed according to the revised Atlanta classification. The interobserver agreement was calculated among all reviewers and subgroups, that is, expert and nonexpert reviewers; interobserver agreement was defined as poor (</=0.20), fair (0.21-0.40), moderate (0.41-0.60), good (0.61-0.80), or very good (0.81-1.00). RESULTS: Interobserver agreement among all reviewers was good (0.75 [standard deviation, 0.21]) for describing the type of acute pancreatitis and good (0.62 [standard deviation, 0.19]) for the type of peripancreatic collection. Expert radiologists showed the best and nonexpert clinicians the lowest interobserver agreement. CONCLUSIONS: Interobserver agreement was good for the revised Atlanta classification, supporting the importance for widespread adaption of this revised classification for clinical and research communications
Caracterización de síntomas psiquiátricos, eventos adversos en la infancia y resiliencia en estudiantes de la Facultad de Ciencias para la Salud de la Universidad de Caldas
No full textIlustracionesspa:Introducción: Se ha descrito un aumento progresivo de problemas mentales en adolescentes, incluyendo a la población universitaria, especialmente en el área de la salud. Factores protectores como la resiliencia y factores de riesgo como eventos adversos en la infancia, se han relacionado con desenlaces en la salud mental. Objetivo general: Caracterizar síntomas psiquiátricos, eventos adversos en la infancia y resiliencia en los adolescentes y adultos jóvenes de primer semestre del año 2020 de los programas de pregrado de la facultad de Ciencias para la Salud de la Universidad de Caldas
Materiales y métodos: Estudio descriptivo, transversal, correlacional, mediante una encuesta virtual incluyendo el SRQ (Self Reporting Questionnaire), escala de resiliencia de Wagnild y Young y preguntas relacionadas con eventos adversos en la infancia.
Resultados: Participaron 108 estudiantes con edad media de 19,6 años. Hubo presencia de síntomas afectivos en 6,4%. El nivel de resiliencia más frecuentemente encontrado fue “medio” y el evento adverso en la infancia más comúnmente reportado fue el maltrato. Se demostró asociación entre haber estado expuesto a eventos adversos en la infancia tanto con presencia de síntomas que comprometen la salud mental como con afectación de uno de los dominios de resiliencia; Asimismo, hubo asociación entre presencia de dichos síntomas con afectación de los dominios de la resiliencia.
Discusión: Se pudo identificar riesgo de alteraciones de la salud mental en los estudiantes, resaltando la asociación con eventos adversos en la infancia y la resiliencia.eng:Introduction: A progressive increase in mental problems has been described in adolescents, including the university population, especially in the health area. Protective factors such as resilience and risk factors such as adverse events in childhood have been related to mental health outcomes. Objective: Characterize psychiatric symptoms, adverse events in childhood and resilience in adolescents and young adults in the first semester of 2020 of the undergraduate programs of the Faculty of Health Sciences of the University of Caldas.
Materials and methods: Descriptive, cross-sectional, correlational study, through a virtual survey including the SRQ (Self Reporting Questionnaire), Wagnild and Young resilience scale and questions related to adverse childhood experiences.
Results: A total of 108 students with a mean age of 19.6 years participated in the study. There was presence of affective symptoms in 6.4% of the participants. The most frequent level of resilience was “medium” and the most commonly reported adverse event was child maltreatment. An association between being exposed to adverse childhood experiences was demonstrated with both, the presence of symptoms that compromise mental health as well as with the affectation of one of the resilience domains. Likewise, there was an association between the presence of those symptoms with the affectation of the resilience domains.
Discussion: It was possible to identify the risk of mental health disorders in the students, highlighting the association with adverse events in childhood and resilience.Resumen / 7 Introducción / 1. Planteamiento del problema y justificación / 1.1 Estudios previos realizados con estudiantes universitarios / 1.1.1 Epidemiología / 1.1.2 Trastornos y problemas mentales / 1.1.3 Factores protectores / 1.2 Justificación / 2. Marco teórico / 2.1 Salud mental / 2.2 Trastornos mentales / 2.2.1 Trastorno depresivo / 2.2.2 Trastorno de ansiedad / 2.2.3 Trastorno bipolar de inicio temprano / 2.3.4 Trastorno de falta de atención/hiperactividad / 2.2.5 Trastorno de conducta / 2.2.6 Trastorno obsesivo compulsivo / 2.2.7 Trastorno por consumo de sustancias / 2.3 Problemas mentales / 2.4 Suicidio y autolesión en adolescentes / 2.5 Eventos adversos en la infancia (ACEs) / 2.6 Conflicto armado y salud mental / 2.7 Impacto de las enfermedades mentales / 2.7.1 Morbimortalidad / 2.7.2 Años perdidos y discapacidad / 2.7.3 Económicos / 2.7.4 Pobreza / 2.7.5 Alteraciones familiares y sociales / 2.8 Factores relacionados con problemas afectivo comportamentales en jóvenes / 2.8.1 Factores prenatales / 2.8.2 Factores neurobiológicos / 2.8.3 Influencia social en la adolescencia / 2.8.4 Desarrollo del adolescente / Caracterización de síntomas psiquiátricos, eventos adversos en la infancia y resiliencia / 2.8.5 Adolescencia como periodo crítico / 2.9 Resiliencia / 2.10 Importancia de las redes de apoyo / 2.11 Estado del arte / 2.11.1 Salud mental en adolescentes / 2.11.2. Salud mental en estudiantes universitarios / 2.11.3 Resiliencia y factores protectores en salud mental de los adolescentes / 2.11.4 Eventos adversos en la infancia (ACEs) y salud mental en adolescentes / 2.11.5. SARS-Cov2 y salud mental en adolescentes y estudiantes / 2.12 Hipótesis del estudio / 2.13 Objetivos / 2.13.1 Objetivo general / 2.13.2 Objetivos específicos / 3. Metodología / 3.1 Tipo de estudio / 3.2 Población / 3.4 Selección de los participantes / 3.5 Variables / 3.6 Técnicas de recolección de información / 3.6 Procesamiento de los datos y análisis estadístico / 3.8 Consideraciones éticas / 3.9 Instrumentos / 3.9.1 SRQ (Self Reporting Questionnaire) / 3.9.1.1 Determinación de la puntuación / 3.10 Escala de resiliencia de Wagnild y Young / 3.10.1 Ecuanimidad / 3.10.2 Perseverancia / 3.10.3 Confianza en sí mismo / 3.10.4 Satisfacción personal / 3.10.5 Sentirse bien solo / 3.11 Interpretación / 3.12 Preguntas para identificar eventos adversos en la infancia (ACEs) / 4. Resultados / 4.1 Riesgo de síntomas afectivos y comportamentales / Caracterización de síntomas psiquiátricos, eventos adversos en la infancia y resiliencia / 5 4.2 Identificación del riesgo / 4.2.1 Preguntas 1-20 (11 o más respuestas afirmativas) / 4.2.2 Preguntas 21 a 25 (Puntuación individual) / 4.3 Resiliencia / 4.3.1 Escala de resiliencia (Wagnild y Young) / 4.4 Eventos adversos en la infancia (ACEs) / 4.5 Asociaciones / 4.5.1 Self Reporting Questionnaire y resiliencia / 4.6 ACEs y SRQ / 4.7 ACEs y resiliencia / 5. Discusión / 5.1 Salud mental en adolescentes y universitarios / 5.2 ACEs y salud mental / 5.3 Resiliencia y salud mental / 5.4 SARS-Cov 2 y salud mental en estudiantes adolescentes / 5.5 SARS-Cov2 y resiliencia / Conclusiones / 6.1 Reflexiones sobre salud mental y pandemia por SarsCov2 / 6.3 Limitaciones del estudio / 6.4 Recomendaciones / AnexosEspecialización médico - quirúrgicaEspecialista en Pediatrí
