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Identificación de anticuerpos irregulares y su prevalencia en pacientes transfundidos en el centro zonal de fraccionamiento de la provincia de El Oro, 2022-2023=

 

Identification of irregular antibodies and their prevalence in transfused patients in the zonal fractionation center of the province of El Oro, 2022-2023

 


= 1

William Arturo Calderón Morán<= span style=3D'color:black'>

 

https://orcid.org/0009-0006-3240-110X

 

 

Universidad Católi= ca de Cuenca, Cuenca, Ecuador

william.calderon.84@est.ucacue.edu.ec=

= 2

Enmanuel Isidoro Guerrero Quir= oz

 

https://orcid.org/0000-0002-7976-1771

 

 

 Universidad Católica de Cuenca, Instit= uto del Cáncer SOLCA-Cuenca, SERMEDIC (Servicios Médicos Integrales)

enmanuel.guerrero@ucacue.edu.ec

 

 =

 

Artículo de Investigación Científica y Tecnológica

Enviado: 18/08/2024

Revisado: 13/09/2024

Aceptado: 01/10/2024

Publicado:10/10/2024

 DOI: = https://doi.org/10.33262/ap.v6i4.545       

<= span lang=3DEN-US style=3D'font-size:8.0pt;line-height:115%;font-family:"Times= New Roman",serif; mso-fareast-font-family:"Times New Roman";color:blue;mso-ansi-language:EN= -US'> 

 

&= nbsp;

Cítese: <= /b>

 

 

Calderón Morán, W. A., & Guerrero Quiroz, E. I. (2024). Identificación de anticuerpos irregulares = y su prevalencia en pacientes transfundidos en el centro zonal de fraccionamie= nto de la provincia de El Oro, 2022-2023. AlfaPublicaciones, 6(4), 41–58. https://doi.org/10.33262/ap= .v6i4.545

 

 

 

ALFA PUBLICACIONES, es una revista multidisciplinar= , trimestral, que se publicará en soporte electrónico tiene como misión contribu= ir a la   formación de profesionales competentes con visión humaníst= ica y crítica que sean capaces de exponer sus resultados investigativos y científicos en la misma medida que se promueva mediante su intervención cambios positivos en la sociedad. https://alfapubli= caciones.com 

La revista es editada por la Editorial Ciencia Digital (Editorial de prestigio registrada en la Cámara Ecuatoriana de Libro con No de Afiliación 663) www.celibro.org.ec

 

 

 

Esta revista está protegida ba= jo una licencia Creative Commons Attribution Non Commercial No Derivatives 4= .0 International. Copia de la licencia: http://creativecommons.org/licenses/by-nc-nd/4.0/

 

Palabras claves:

Aloa= nticuerpos, incompatibilidad ABO, pruebas cruzadas, reacción hemolítica.

 

Resumen =

Introducción: La identificación de Anticuerpos Irregulares (AI) es un pro= ceso de vital importancia para toda muestra de sangre que requiera una transfusión. Por tal razón, se recomiendan pruebas pre transfusionales ta= les como la clasificación ABO, Rh y pruebas cruzadas. Objetivo: Identificar la prevalencia de AI en pacientes transfundidos del centro zo= nal de fraccionamiento de la provincia de El Oro, 2022-2023. Métodos: = Se realizó un estudio descriptivo retrospectivo no experimental, analítico y transversal. Para el rastreo se utilizó la tarjeta ID-card Liss/coombs de= 6 microtubos que contiene anti-IgG y anti-C3d dentro del gel y el reactivo ID-Diacell I-II-III. Además, para la identificación se utilizó el panel d= e11 células y fenotipos del factor Rh (anti-C, anti-E, anti-c, anti-e y anti-= K) de de la misma casa comercial. Resultados: El anticuerpo prevalente fue el anti-E con 16 casos (28,6%), teniendo mayor frecuencia en el sexo femenino (62,5%) y en pacientes con edades superior a los 45 años (21,5%)= . Conclusión: La prevalencia de AI en pacientes transfundidos del centro de francionami= ento de la provincia de El Oro, es similar a lo reportado en otros artículos. = El conocer la identificación AI, permite realizar la fenotipificación correc= ta del sistema Rh de manera habitual y así disminuir el peligro de reacciones adversas, asociadas a transfusiones. Área de estudio general:  Banco de sangre. Área de estudio específica: Inmunohematología. Tipo de estudio: Artículo origi= nal.

 

 

Keywords:

Alloantibodies, ABO incompatibility, crossmatch, hemolytic reaction.

&= nbsp;

Abstract=

Introd= uction: The identification of Irregular Antibodies (AI) is a vitally important process for any blood sample that requires a transfusion. For this reason, pre-transfusion tests such as ABO, Rh classification and cross-matching a= re recommended. Objective: To identify the prevalence of AI in transf= used patients from the zonal fractionation center of the province of El Oro, 2022-2023. Methods: A descriptive, retrospective, non-experimental= , analytical, and cross-sectional study was conducted. For tracking, the ID-card Liss/coombs card with 6 microtubes containing anti-IgG and anti-C3d within the gel and the ID-Diacell I-II-III reagent were used. In addition, the p= anel of 11 cells and phenotypes of the Rh factor (anti-C, anti-E, anti-c, anti= -e, and anti-K) from the same commercial house were used for identification. = Results: The prevalent antibody was anti-E with 16 cases (28.6%), having a higher frequency in females (62.5%) and in patients over 45 years of age (21.5%)= . Conclusion: The prevalence of AI in transfused patients from the fractionate center of the province of El Oro is like that reported in other articles. Knowing t= he AI ​​identification allows for the correct phenotyping of the= Rh system in a routine manner and thus decrease the risk of adverse reactions associated with transfusions.

 

 

 

 

Introducción<= /b>

La identificación de Anticuerpos Irregulares (AI) es un proceso de vital importancia para las muestras de sangre que requieran una transfusión. Corresponden a Anticuerpos (Ac) distintos de los natura= les anti-A o anti-B que pueden surgir por exposición a Antígenos (Ag) extraños de Glóbulos Rojos (GR) causado por transfusión, trasplante o por incompatibilidad materno-fetal. En algunos casos pueden detectarse en personas sin historial de transfusión o embarazo (Bharathan et al., 2019). = Cabe resaltar la importancia de la identificación de los AI previo a las transfusiones sanguíneas (Chen et al., 2023).

Con respecto al éxito de u= na transfusión es necesario establecer la calidad del donante, la oportuna necesidad transfusional y la aplicación correcta de un protocolo de Prue= bas Pretransfusionales (PPT) para garantizar la transfusión y prevenir el riesgo que pueden presentarse (Mahapatra et al., 2023). En consecuencia, una equivocación complica la vida del paciente.=

La Organización Mundial de la Salud (OMS, 2024), declara en su manual sobre el uso clínico de la sangre: “Cada hospital debe contar con procedimientos operativos estándar que aseguren que los componentes sanguíneos a transfundir serán compatibles con los Glóbulos Rojos del paciente, así como con los anticuerpos presentes en su plasma”. Previo a la transfusión se debe realizar PPT para asegurar la compatibilidad donante-receptor y determinar la presencia de aloanticuerpos y/o autoanticuerpos (Yazer et al., 2022).

En Ecuador, existe el Reglamento a la Ley Orgánica de Salud, Capítulo II (de la Sangre, sus componentes y derivados) representa: Art. 5.= - El Ministerio de Salud Pública establecerá normas y procedimientos para la donación, fraccionamiento, estudios serológicos (tamizaje), pruebas pretransfusionales, uso clínico y vigilancia de las reacciones transfusiona= les. Incluyendo la caracterización de AI en todos los donantes voluntarios de sa= ngre y pacientes primeramente ante el uso de los componentes sanguíneos (= Presidencia de la Republica del Ecuador, 2008).

De esta forma se identifica el problema originado por incompatibilidad sanguínea. La misma que protege sobre todo la integridad y seguridad del paciente. Con el propósito de minimizar los riesgos se recomiendan PPT como la clasificación ABO y Rh del paciente, la detección de Ag, pruebas cruzadas y la identificación de AI (Escamilla-González et al., = 2021).

A nivel local, entre el año 2018 y 2020, un estudio realizado = en el Hospital de Especialidades Eugenio Espejo (Quito-Ecuador), encont= ró al Anti-E como el Ac con mayor frecuencia) y hubo además una cantidad considerable de aloanticuerpos que no habían sido identificados (71,05%) (<= /span>Caicedo & Ortega, 2023).

La aloinmunización se provoca por un trastorno inmunológico de= los eritrocitos que contienen Ag de superficie que en su mayoría son extraños al receptor (Adewoyin et al., 2023). Además, provoca la activación del sistema inmune, causando respuestas inmunológicas, lo que desencadena la sensibilización y producción de aloanticuerpos contra las células eritrocitarias (Adewoyin et al., 2023). En caso de recibir un segundo conta= cto, el Ag estimulará la producción de una mayor cantidad de aloanticuerpos, causando la correspondiente destrucción eritrocitaria de las células del donante dentro del receptor (Arthur et al., 2017).

Las Reacciones Transfusionales Hemolíticas Tardías (RTHT) se producen aproximadamente 24 horas luego de recibir el componente sanguíneo = (Alaoui et al., 2022), y son ocasionadas por Ac antieritrocitarios especialmente lo= s Ag del sistema sanguíneo Rh (RH), Kidd (JK), Duffy (FY) o Kell (KEL) (<= span style=3D'font-size:12.0pt;line-height:115%;font-family:"Times New Roman",se= rif; mso-fareast-font-family:"Times New Roman"'>Ranjan et al., 2023).

El conocer el tipo de aloanticuerpo presente en pacientes transfundidos, ayudará a tomar medidas orientadas a la necesidad e importan= cia de realizar una fenotipificación extendida rutinaria para el paciente y la unidad sanguínea a transfundir.

Es decir, con la ejecución de este artículo, se conocerá los riesgos de aloinmunización en los pacientes, la misma que facilitaría el despacho oportuno de concentrados sanguíneos compatibles por parte del serv= icio del banco de sangre.

Metodología

Se trató de un estudio descriptivo retrospectivo, no experimen= tal, analítico y transversal que abarcó un período de dos años (2022-2023). Este estudio se ejecutó en todas las muestras aprobada= s de pacientes que solicitaron componentes sanguíneos del banco de sangre del ce= ntro zonal de fraccionamiento de la provincia de El Oro. También se utilizar= on como referencia muestras con AI y/o PPT incompatibles.

Se utilizó una fuente de información secundaria de los registr= os del sofware e-Delphyn (Bitrodiagnóstico Cía. Ltda-Madrid- España). Entre las variables analizadas estuvieron: género, rangos etarios, AI, antecedentes transfusionales y unidades transfundidas que fueron despachadas.

Fueron incluidos todos los pacientes con resultados de PPT. Las limitaciones de este estudio se relacionaron con errores de trascripción y = la información incompleta de las ordenes médicas con los datos de la solicitud= de los componentes sanguíneos.

Se excluyeron para la fenotipificaci= ón a los pacientes transfundidos en los últimos tres meses, debido a la presenci= a de eritrocitos circulantes transfundidos, que impedían el fenotipado exacto del grupo sanguíneo (Escamilla-Guerrero & García-Rosales, 2023).

Para las PPT y el Rastreo de Anticuerpos Irregulares (RAI) se utilizaron la prueba de antiglobulina indirecta. El RAI se realizó con un equipo automatizado (BANYO), las mismas= que se procesaron con la tarjeta ID-card Liss/combs, en 6 microtúbulos que contenían anti-IgG y anti-C3d dentro del gel y el reactivo ID-Diacell I-II-= III de la marca BIO-RAD.

Para la identificación de AI se util= izó un panel de células (11 células con Ag conocidos) y fenotipos del factor Rh (anti-C, anti-E, anti-c, anti-e y anti-K) de la misma casa comercial, con el fin de fenotipar tanto al paciente y a las unidades a transfundir cuando era necesario.

Por otro lado, para las características demográficas, clínicas= y hematológicas mediante el cálculo de proporciones con intervalos de confian= za del 95%. Para la comparación de la identificación y prevalencia de los AI de mayor importancia clínica a consecuencia del número de transfusiones sanguí= neas y la relación de distribución de las características de género de los pacie= ntes transfundidos acorde a los diversos rangos etarios, se analizaron con la pr= ueba chi cuadrado de Pearson. Se utilizó el programa de IBM SPSS Statistics V 0.26 para la integración de la data.

Resultados

En el Banco de Sangre del Centro Zonal de Fraccionamiento de la provincia de El Oro se realizó PPT a 17.266 unidades de GR, de un tot= al de 6.202 muestras de sangre recibidas durante el periodo antes mencionado. = Así mismo, se detectó la presencia de 56 AI. Se estableció una prevalencia de AI del 0,90%.

La poblac= ión de estudio mostró una distribución demográfica diferente entre los sexos, siendo la mayor frecuencia para las mujeres inmunizadas (62,5%), con antecedente de transfusiones previas (63%), como se muestra en la figura 1.=

&nbs= p;

Figura 1

Frecuencia de transfusiones sanguíneas previas en pacientes de acuerdo con su género

 

Como se muestra tabla 1, se observa que el grupo etario con mayor repetición fueron adultos mayores de 60 años o más, con una frecuencia de 53,6% de casos; así mismo, para los niños de 6 a 11 años e infante (0= a 5 años), ambas registraron un paciente (1,8%); la edad promedio fue de 56,9 años= , con un rango que osciló entre 1 y 96 años. <= /p>

En relaci= ón con la categorización de transfusiones, fueron los tetratransfundidos los m= ás frecuentes y representaron 24 pacientes (42,9%); el inferior predominio fue para los pacientes politransfundidos (pacientes con cinco transfusiones o m= ás) y los no transfundidos, ambas registran cinco transfusiones (8,9%).

El promed= io de transfusiones fue de seis unidades de GR, con un rango entre 1 y 23 unid= ades a transfundir. Por esta razón, 43 pacientes fueron transfundidos previamente (76,8%), con un resultado de prevalencia en el sexo femenino (77,1%).<= /o:p>

El diagnóstico primario de la población de estudio fue la anemia no específica como causa principal (71,4%). El grupo sanguíneo de mayor frecuente fue O Rh positivo (66,1%), y el grupo B Rh positivo (1,8%) tuvo la menor frecuencia.= Las demás características del estudio se describen, como se muestra en la tabla= 1.

Tabla 1

Características y frecuencia en los pacientes transfundidos

Variables

Frecuencia n=3D56

Porcentaje %

Sexo

Femenino

35

62,5

Masculino

21

37,5

 

 

 

 =

Tabla 1

Características y frecuencia en los pacientes transfundidos (continuación)

Variables

Frecuencia n=3D56

Porcentaje %

 

Grupo etario

(años)<= o:p>

>61      

30

53,6

 

30 a 60    

19

33,9

 

18 a 29         

5

8,9

 

6 a 17          

1

1,8

 

0 a 5

1

1,8

 

 

 

 

 

Grupo/f= actor

A+

14

25,0

 

B+

1

1,8

 

O+

37

66,1

 

O Neg

4

7,1

 

 

 

 

 

Diagnós= tico

Anemia

40

71,4

 

Cáncer

3

5,4

 

Choque séptico

1

1,8

 

Diabetes mellitus

1

1,8

 

Fractura de fémur

1

1,8

 

Hemorragias

3

5,4

 

Infarto cerebral

2

3,6

 

Purpura

2

3,6

 

Tumor

3

5,4

 

 

 

 

 

Transfu= siones previas

Si

43

76,8

 

No

13

23,2

 

 

 

 

 

Categor= ización de transfusiones

Monotransfundido     

10

17,9

 

Ditranfundidos            <= /span>

6

10,7

 

Tritransfundidos           

6

10,7

 

Tetratransfundidos          

24

42,9

 

Politransfundidos          

5

8,9

 

No transfundido

5

8,9

 

 

 

En relación del género con el RAI el sexo femenino fue el mayor predominante con 30 mujeres que fueron positivos (53,6%) en comparación a los hombres con casos18 (32,1%), como se muestra e= n la tabla 2.

 

Tabla 2

Relación entre la presencia de anticue= rpos irregulares positivos y el género

Género

Positivo=

n (%)

Negativo=

n (%)

Autoanticuerpos n (= %)

Total

n (%)

Femenino

30 (53,6)

5 (8,9)<= /span>

0=

35 (62,5)

Masculino

18 (32,1)

2 (3,6)<= /span>

1 (1,8)<= /span>

21(37,5)=

Total

48 (85,7)

7 (12,5)=

1 (1,8)<= /span>

56 (100)=

 

Como se muestra en la figura 2, el 86% de los pacientes tuvier= on RAI positivos, con una notable diferencia del 12% de muestras negativas.

Figura 2

Frecuencia de anticuerpos irregulares en los pacientes transfundidos entre 2022 y 2023

Con respecto a los resultados de la especificidad de los AI, de los 20 Ac identificados en 56 pacientes, 16 fueron Anti-E (28,6%), cuatro Anti-Jka y Anti-D (7,1%). Las especificidades con menor frecuencia fueron n= ueve casos Anti-c, Anti-C, Anti-e, Anti-Fyb, Anti-k, Anti-K, Anti-Lea, Anti-Lua y Anti-Lub (como se muestra en la figura 3).

Así mismo, en siete casos se manifestaron asociación de dos Ac= con las composiciones Anti-D/Anti-K, Anti-E/Anti-c, Anti-E/Anti-K, Anti-E/Anti-= Lua, Anti-E/Anti-N, Anti-Fya/Anti-E y Anti-k/Anti-Kpb. Además, se observaron nue= ve Ac indeterminados que representaron el 16,1%. Para finalizar, los Ac del sistema Rh correspondieron al 46,5% de predominio en los casos estudiados, = como se muestra en la figura 3.

 

 

 

Figura 3

Prevalencia = de aloinmunización por tipo de anticuerpo irregular presentes en los pacientes transfundidos=

 

En cuanto, a la población con AI, evidentemente fue el anti-E = que se hallaba en el género femenino, dentro del grupo etario mayor de 45 años (21,5%), como se muestra en la figura 4.

Figura 4

Frecuencia de aloanticuerpos en pacientes del género femenino mayor de 45 años=

 

Discusión

= La principal causa de Reacciones Adversas (RAD), e incompatibilidad sanguínea en situaciones de emergencia es la aloinmunización de Ac de alta intensidad dirigidos contra Ag en los pacientes. La aloinmunización eritrocitaria tiene importantes contraindicaciones clínicas (Akemi et al., = 2020). Las reacciones transfusionales, ya sean inmediatas o tardías, pueden desaparecer con el tiempo o volver a ocurrir al recibir otra transfusión de= bido a la aloinmunización (Schonewille et al., 2006).

El presente artículo fue diseñado pa= ra identificar la prevalencia de AI en pacientes transfundidos del centro zonal de fraccionamiento de la provincia= de El Oro, 2022-2023. En cuanto a la prevalencia de AI en las muestras aceptadas para los receptores sanguíneos, se encontró que fue 0,90% en la población. Hui et al. (2023) reportó una prevalenci= a de 0,51% de aloinmunización en 778 casos, y otro estudio realizado por Cruz et= al. (2022), obtuvo una prevalencia de 3,1%. Por lo tanto, la prevalencia de est= e estudio se encuentra dentro de lo reportado por la literatura, y esto se debe en pa= rte a la similitud entre las demás características clínicas de los pacientes y = las circunstancias de la aloinmunización (Cruz et al., 2022; Ali et al., 2023).=

Cabe considerar, que las característ= icas de la población en este estudio, en relación con su amplio rango de edad (1= y 96 años), fue debido a que el banco de sangre en cuestión proporciona hemocomponentes a toda la población en general. Con afinidad al grupo ABO y= el factor Rh no se encontró correlación con relación a la inmunización. Sin embargo, algunos estudios indican que aquellos individuos que pertenecen al grupo O tienen un factor protector para el desarrollo de aloanticuerpos por= su capacidad de conservar las isoaglutininas y por ende reducir el riesgo de desarrollar enfermedades peligrosas (Arend, 2020).

Las características de los AI principales coexistieron el anti-E, Anti-Jka y Anti-D. En consecuencia, est= os se encontraban dentro de los cuatro Ag con tende= ncia a ser más inmunogénicos, y en su mayoría son Ac de tipo IgG con capacidad de activar el sistema de complemento ocasionando hemolisis de tipo extravascul= ar y enfermedad hemolítica del recién nacido (EHRN) (Karimi et al., 2007; Koelew= ijn et al., 2008). =

Mediante el rastreo de AI, se identi= ficó que la mayoría de las muestras provocaron incompatibilidad al momento de realizar las PPT en la selección de paquetes globulares. De modo similar en los artículos encontrados, la mayoría de los AI reconocidos estaban relacionados con el sistema Rh (anti-E y anti-D) y el sistema Kidd (anti-Jka), resultados que concuerdan con los estudios elaborados por Maia = et al. (2023), Rosário et al. (2023), Ali et al. (2023) y Hui et al. (2023), tal como los casos del anti-E y Anti-D que representaban los= Ac predominantes en los pacientes de este estudio. Estos hallazgos, sumados a = la variabilidad genética, antecedentes transfusionales y características demográficas, contribuyen a incrementar la tasa de inmunogenicidad y aloinmunización (De Oliveira et al., 2023; Medina-Muñoz et al., 2023).=

Como anteriormente se ha explicado la presencia de aloanticuer= pos eritrocitarios dificulta la selección de componentes sanguíneos ante la necesidad transfusional del paciente (Yashinta & Dia, 2024). = En varias ocasiones, se hace imposible disponer de este recurso ante una emergencia, y como se demostró en esta investigación el mayor riesgo se presentaba en aquellos pacientes politransfundidos que por su patología de = base tenían requerimientos transfusionales con mayor frecuencia y que eran prope= nsos a eventos adversos relacionados con la transfusión.

Conjuntamente la aloinmunización y el mayor riesgo de RAD se manifestó en los pacientes transfundidos que por su patología de base, necesitan continuos requerimientos transfusionales. Es decir, factores como la discrepancia antigénica entre donante y receptor, el sistema inmunológico del receptor, el efecto inmunomodulador causado por la transfusión y el número de transfusiones están asociados con mayores RAD (B= auer et al., 2007; Mejía et al., 2018).

De lo anterior Mejía et al. (2018), expuso que la inmunización se correlaciona más con la capacidad del sistema inmune de cada individuo y con el número de unidades transfundidas. Así mis= mo Chung et al. (2023), demostró que la exposición a varios Ag influye en la frecuencia de Ac y posteriormente afectan la inmunogenicidad, y cuando se transfunde al paciente con la misma sangre incompatible, varia las condicio= nes de aloinmunización. En el presente estudio, no se halló asociación entre el número de transfusiones y la presencia de AI.

El género puede incidir en la aloinmunización. Se reportó que = las mujeres desarrollaron mayores frecuencias de AI, frente a los hombres. Estos resultados coinciden con otros estudios (Cadena-Alvarado & Solano-Ramírez, 2024)<= /span>. El motivo, se puede explicar por la respuesta inmune hacia A= g no propios en los GR, que sucede posteriormente a la exposición, como en el embarazo (Hendrickson & Tormey, 2016).

Los autoanticuerpos indeterminados pueden ocasionar consecuenc= ias como la panaglutinación (reacción del suero del paciente con todos los GR analizados), enfermedades autoinmunes y otras (Gawande et al., 2024; Giuliani et al., 2018; Kokoris et al., 2022; Yu & Wang, 2014). Las altas concentraciones de Ac generan un efecto de enmascaramiento, que lleva a la detección de aloanticuerpos indeterminados<= /a> (Pessoni et al., 2018). Ji et al. (2022) indicó que los autoanticuerpos en = su mayoría reaccionaban al calor (37°C), pero no están asociados a inducir hemólisis intravascular. Esto se debe a que las inmunoglobulinas propias de= los eritrocitos del paciente se encuentran en concentraciones muy bajas para dar manifestaciones de hemólisis extravascular.

Como limitaciones de este artículo, se puede indicar que se de= bido al tamaño de la muestra, se dificultó las asociaciones estadísticas. Se recomienda realizar análisis detallados, con periodos de seguimiento más extensos para fortalecer las asociaciones encontradas.

 

Conclusión

·         La prevalencia de AI en la muestra experimentada, tuvo de 16 casos (28,6%) de anti-E. Al desarrollar aloanticuerpos eritrocitarios en el sistema Rh, se dificulta la selección y= el cruce de unidades compatibles. En consecuencia, al conocer la identificació= n de los sistemas involucrados en el desarrollo de AI, permitirá realizar la fenotipificación correcta del sistema Rh de manera habitual, con la finalid= ad de despachar unidades compatibles, y así disminuir el peligro de inmunizaci= ón y RAD asociadas a transfusiones.

Conflictos de interés

Los autores declaran no tener conflicto de interés en relación= con el artículo presentado.

Declaración de contribución de los autores

Autor 1: Participó en el diseño de la investigación, recolecci= ón de datos, el análisis de resultados y la elaboración del contenido, y así m= ismo el informe final.

Autor 2: Asistió en la revisión y aprobación de los resultados= en el análisis y mejora de la investigación para elaborar la culminación de resultados y conclusiones.

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El artículo que se publica es de exclusiva responsabilidad de los autores y no necesariamente reflejan el pensamiento = de la Revista Alfa Publicaciones.

 


El artíc= ulo queda en propiedad de la revista y, por tanto, su publicación parcial y/o t= otal en otro medio tiene que ser autorizado por el director de la Revista Alfa Publicaciones.<= /o:p>

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ISSN: 2773-7330

Vol. 6 No. 4.  pp.= 4158. octubre - diciembre 2024

www= .alfapublicaciones.com

  =

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