Atlas of Dermatology: Inflammatory, Infectious and Tumoral Skin Diseases

ISBN-13: 9783030841096 / Angielski / Miękka / 2023 / 794 str.

Adriana Motta; Luis Fernando Gonz?lez; Gonzalo Garc?a

Opis

Dermatology is the science responsible for the study of the skin, mucous membranes (oral and genital) and cutaneous appendages, while dermatopathology focuses on its microscopic study. Although the two fields are closely related, in many cases the identification of dermatological diseases is mainly clinical and depends on the physician’s ability and experience. The purpose of this atlas, which collects over 900 clinical and histological photographs in high resolution, is to illustrate and describe the most frequent skin diseases on the basis of clinical cases. Offering a complete guide to the etiology, epidemiology, clinical features, histologic findings and diagnosis of the main skin diseases divided into three subgroups (inflammatory, infectious, or tumoral), it represents an invaluable resource for all medical students, residents, clinicians, and investigators learning dermatology.

Spis treści

I.    INFLAMMATORY SKIN DISEASES

Chapter 1. Papulosquamous and eczematous dermatoses

1. Dermatitis or eczema

a. Contact dermatitis

i. Allergic contact dermatitis

ii. Irritant contact dermatitis

b. Atopic dermatitis

c. Aesteatotic dermatitis

d. Nummular dermatitis

e. Gravitational Dermatitis

f. Seborrheic dermatitis

g. Palmoplantar vesicular dermatitis

i. Ponfólix

ii. Chronic vesicle-bullous dermatitis of the hands

iii. Hyperkeratotic dermatitis of the hand

iv. Ide reaction

h. Autosensitization dermatitis

i. Herpetic eczema or varicelliform eruption of Kaposi

j. Infectious dermatitis

k. Chronic simple liquor

l. Nodular prurigo

m. Plantar Juvenile Dermatosis

2. Psoriasis

a. Psoriasis vulgaris or plaques

b. Guttate Psoriasis

c. Pustular psoriasis

i. Located

1. Palmoplantar Pustulosis

2. Continuous acrodermatitis of Hallopau

ii. Generalized

1. Acute generalized pustulose (von Zumbusch)

2. Annular pustular

d. Inverse psoriasis

e. Scalp Psoriasis

f. Genital Psoriasis

g. Erythrodermic psoriasis

h. Nail Psoriasis

i. Psoriatic arthropathy

j. HIV-associated psoriasis 

3. Lichen and lichenoid ​​reactions

a. Lichen planus

i. Lichen planus pillar

ii. Oral lichen planus

iii. Actinic lichen planus

iv. Lichen planus pigmentosa

v. Acute exanthematic flat lichen

vi. Lichen inverse plane

vii. Genital lichen planus

viii. Hypertrophic lichen planus

ix. Bullous or pemphigid lichen planus

x. Annular lichen planus

xi. Linear lichen planus

xii. Ungular lichen planus

xiii. Ulcerative lichen planus

b. Lichenoid reaction

c. Fixed pigmented erythema

d. Lichen Crisp

e. Lichen striatum

f. Persistent dyschromic erythema

g. Chronic Lichenoid Keratosis 

Chapter 2. Other Papular, erythematous and scaly diseases

1. Pityriasis Lichenoid
2. Pityriasis liquenoid and acute varioliform
3. Pityriasis, chronic lichenoid
4. Pityriasis liquenoid leukcomelandermal
5. Pityriasis rubra pilaris
6. Pityriasis rosea
7. Pityriasis rotunda
8. Granular Parakeratosis 

Chapter 3. Inflammatory diseases of pilose follicle

1. Alopecia

a. Non-scarring

i. Alopecia areata

ii. Alopecia universalis

iii. Alopecia totalis

iv. Patchy alopecia areata

v. Diffuse Alopecia areata

vi. Ophiasis alopecia

vii. Sisaifo or reverse ophiasis alopecia

viii. Androgenic Alopecia

ix.Telogen effluvium

x. Trichotillomania

xi. Traction alopecia

xii. Temporal triangular alopecia

xiii. Lipedematous Alopecia 

b. Scarring

i. Central centrifugal scarring alopecia

ii. Lichen planus pilaris

1. Classic type

2. Fibrosing frontal alopecia

3. Graham-Little-Piccardi syndrome

iii. Mucinous Alopecia

iv. Discoid lupus

v. Keloid acne of the neck

vi. Decalvating folliculitis

vii. Dissecting folliculitis 

2. Inflammatory folliculitis

a. Pseudofolliculitis of the beard

b. Other follicular disorders

c. Suppurative Hydradenitis 

Chapter 4. Inflammatory diseases of the sebaceous and apocrine glands 

1. Acne

a. Degrees of severity: mild, moderate and severe

b. Acne conglobata

c. Acne fulminans

d. Acne necroticans

e. Acne ointment or cosmetic

f. Steroid or medication-induced acne

g. Hormonal acne

h. Neonatal acne

i. Childhood acne

j. Excoriated acne

k. Occupational acne

l. Radiation acne

2. Rosacea

a. Erythematous-telangiectatic rosacea

b. Papulopustular rosacea

c. Phymatous rosacea

d. Ocular rosacea

e. Rosaceiform Dermatitis

3. Perioral dermatitis 

Chapter 5. Inflammatory skin diseases induced by drugs

1. Drug reactions

a. Morbilliform rash

b. Erythema multiforme

c. Steven-Johnson syndrome

d. Toxic epidermal necrolysis

e. Drug reaction with eosinophilia and systemic symptoms

f. Acute generalized exanthematous pustulosis 

Chapter 6. Inflammatory diseases of the blood vessels with cutaneous involvement

1. Vasculitis

a. Small vessel vasculitis

i. Leukocytoclastic vasculitis

ii. Henoch-Schonlein purple

iii. Acute hemorrhagic edema of childhood

iv. Erythema elevatum diutinum

b. Mixed vasculitis

i. Cryoglobulinemia

ii. Associated with ANCA antibodies

iii. Microscopic polyangiitis

iv. Wegener granulomatosis

v. Churg-Strauss syndrome

c. Secondary

i. Septic vasculitis

ii. Vasculitis associated with inflammatory disorders (disseminated intravascular coagulation)

d. Medium vessel vasculitis

i. Polyarteritis nodosa

e. Vasculitis of large vessels

i. Temporal arteritis

ii. Takayasu arteritis 

Chapter 7. Inflammatory diseases affecting melanocytes 

1. Inflammatory diseases that occur with hyperpigmentation

a. Post-inflammatory hyperpigmentation

b. Persistent dyschromic erythema

c. Lichen planus pigmentosa

d. Melasma

e. Flagellated Erythema

f. Confluent and reticulated papillomatosis of Gougerot and Carteaud

g. Erythema ab igne 

2. Inflammatory diseases that occur with hypopigmentation

a. Vitiligo

b. Post-inflammatory hypopigmentation

c. Lichen sclerosus and atrophic

d. Lichen striatum

e. Pityriasis alba 

Chapter 8. Bullous vesicular inflammatory diseases 

1. Pemphigus

a. Pemphigus vulgaris

i. Mucocutaneous

ii. Vegetant

b. Pemphigus foliaceus

i. Seborrheic or classic

ii. Fogo type selvagem

iii. Senear syndrome - Usher

c. Paraneoplastic Pemphigus

2. Dermatitis herpetiformis

3. Linear IgA dermatosis

4. Bullous Pemphigoid

5. Scarring pemphigoid

6. Pemphigoid gestationis

7. Epidermolysis bullosa acquired 

Chapter 9. Inflammatory skin diseases presented as erythema, urticaria and purpura 

1. Urticaria

a. Allergic urticaria

b. Physical urticaria

c. Cold and heat urticaria

d. Cholinergic urticaria

e. Vasculitic urticaria 

2. Figurate erythemas

a. Annular Erythema Centrifugal

b. Erythema gyratum repens

c. Migratory Necrolytic Erythema

d. Migratory erythema

e. Married Erythema 

3. Purples

a. Purple Pigments

i. Progressive pigmentary dermatosis of Schamberg

ii. Majocchi telangiectodes annular purpura

iii. Gougerot and Blum pigmentary purpuraica lichenoid dermatitis

iv. Lichen aureus

v. Pruritic purpura or eczematoid of Doucas and Kapetanakis 

Chapter 10. Inflammatory connective tissue diseases 

1. Cutaneous lupus

a. Acute lupus erythematosus

b. Subacute lupus erythematosus (SCLE)

i. Annular SCLE

ii. Papulosquamous/psoriasiform SCLE

c. Chronic cutaneous lupus

i. Chronic discoid lupus erythematosus

1. Located

2. Disseminated

ii. Hypertrophic

iii. Lupus panniculitis

iv. Lupus Childblain

v. Lupus tumidus

vi. Bullous lupus

d. Other variants

i. Rowell syndrome

ii. Neonatal Lupus 

2. Dermatomyositis

3. Scleroderma

4. Morphea

5. Scleredema

6. Recurrent Polychondritis

7. Rheumatoid arthritis

8. Graft versus host disease 

Chapter 11. Granulomatous inflammatory diseases

1. Sarcoidosis

2. Annular granuloma

3. Lipoid Necrobiosis

4. Giant cell annular elastotic granuloma

5. Crohn's disease of the skin 

Chapter 12. Inflammatory diseases induced by ultraviolet radiation 

1. Immunologically mediated dermatoses

a. Polymorphic luminic eruption

b. Actinic prurigo

c. Chronic actinic dermatitis 

d. Solar urticaria

e. Hydroa vacciniform

2. Photodermatosis secondary to exogenous agents

a. Photocontact dermatitis

b. Phototoxic and photoallergic dermatitis 

3. Photodermatosis secondary to endogenous agents

a. Congenital erythropoietic porphyria

b. Erythropoietic Protoporphyria

c. Cutaneous porphyria takes

d. Pseudoporphyria

e. Hepatoerythropoietic porphyria 

4. Diseases caused by defects in DNA repair

a. Xeroderma pigmentoso

b. Trichotiodystrophy 

5. Photogravure disorders (present in each respective section)

a. Lupus erythematosus

b. Dermatomyositis

c. Rosacea

d. Atopic dermatitis

e. Seborrheic dermatitis 

Chapter 13. Neutrophilic and eosinophilic inflammatory diseases 

1. Neutrophilic Infiltrates

a. Acute febrile neutrophilic dermatosis (Sweet syndrome)

b. Pyoderma gangrenosum

c. Subcorneal pustular dermatosis (Sneddon-Wilkinson disease)

d. Behcet's disease

e. Neutrophilic dermatosis of the back of the hands

f. Ecrine Neutrophilic Hydradenitis

g. Rheumatoid Neutrophilic Dermatitis 

2. Eosinophilic Infiltrates

a. Facial granuloma

b. Eosinophilic pustular folliculitis

c. Eosinophilic cellulitis

d. Eosinophilic Fasciitis 

Chapter 14. Inflammatory diseases of subcutaneous cell tissue 

1. Lobular Panniculitis

a. Indurated Bazin Erythema or Nodular Vasculitis

b. Pancreatic panniculitis

c. Scleredema neonatorum

d. Fat necrosis of the newborn

e. Post-steroid panniculitis

f. Lupus panniculitis

g. Panniculitis due to dermatomyositis

h. Lipodystrophic Panniculitis

i. Cold panniculitis

j. Sclerosing Lipogranuloma

k. Paniculitis from injected substances

l. Lipodermatosclerosis

2. Septal panniculitis

a. Paniculitis due to alpha 1 antitrypsin deficiency

b. Erythema nodosum 

II. INFECTIOUS SKIN DISEASES 

Chapter 15. Bacterial infections 

1. Staphylococcal and streptococcal infections

a. Impetigo

b. Ectima

c. Erysipelas

d. Cellulitis

e. Acute lymphangitis

f. Necrotizing Fasciitis

g. Folliculitis, boil, anthrax

h. Acute paronychia

2. Staphylococcal and streptococcal toxin syndromes

a. Scalded skin syndrome

b. Toxic Shock Syndrome

c. Toxic Streptococcal Shock Syndrome

d. Scarlet fever

e. Erysipeloid

f. Corinebacterial Infections

g. Erythrasma

h. Keratolysis punctata

3. Gram-negative infections

a. Gangrenous Ectima

b. Infections caused by Bartonella

c. Disease cat scratch

d. Bacillary Angiomatosis

e. Bacteria previously classified as fungi

f. Actinomycosis

g. Nocardiosis 

Chapter 16. Mycobacterial Infections 

1. Leprosy

a. Cutaneous tuberculosis

b. Tubercle chancre

c. Bazin indurated erythema

d. Escrofuloderma

e. Lichen scrofulosorum

f. Lupus vulgaris

2. Acute disseminated miliary tuberculosis

3. Papulonecrotic tuberculosis

4. Tuberculosis verrucous complexion

5. Non-tuberculous mycobacteria 

Chapter  17. Fungal infections 

1. Superficial mycoses

a. Dermatophytosis or ringworm

i. Tinea capitis

ii. Tinea Faciei

iii. Ringworm of the beard

iv. Tinea corporis

v. Inguinal ringworm

vi. Tinea Pedis

vii. Tinea Incognita

b. Cutaneous Candidiasis

i. Oral and perioral candidiasis

ii. Pseudomembranous

iii. Perleche (angular cheilitis)

iv. Atrophic oral candidiasis

v. Hypertrophic oral candidiasis

vi. Genital candidiasis

vii. Candidiasic Intertrigo

viii. Candidatic Perionixix

c. Onychomycosis

d. Pityriasis versicolor

e. Black ringworm

2. Deep mycoses

a. Chromomycosis

b. Mycetoma

c. Sporotrichosis

d. Lobomycosis 

3. Systemic mycoses

a. Blastomycosis

b. Coccidiodomycosis

c. Histplasmosis

d. Paracoccidiodomycosis 

Chapter 18. Virus infections 

1. Enterovirus

a. Hand-foot-mouth disease

b. Herpangina

c. Pseudoangiomatosis eruptive 

2. Herpesvirus (VHH)

a. VHH 1 AND 2: Herpes simplex virus (HSV) types 1 and 2

i. Herpetic gingivostomatitis

ii. Genital herpes

iii. Herpetic eczema

iv. Herpetic Panadizo

v. Herpes gladiatorum

vi. Herpetic folliculitis

vii. Herpes simplex hypertrophic

b. VHH 3: Varicella zoster virus

i. Chickenpox

ii. Congenital chickenpox

iii. Herpes zoster

c. VHH 4: epstein-barr virus

i. Hairy leukoplakia

ii. Ulcers of lipschütz

iii. Hydroa vacciniforme

d. VHH 5: Cytomegalovirus

e. VHH 6: Herpesvirus type 6

i. Exanthem Subitum

f. VHH 7: Herpes virus type 7

i. Pityriasis rosea

g. VHH 8: Herpesvirus type 8

i. Kaposi's sarcoma 

3. Papillomavirus

a. Vulgar warts

b. Flat warts

c. Accumulated condyloma

d. Bowenoid Papulosis

e. Heck disease 

4. Poxvirus

a. Molluscum contagiosum

b. Orf nodule

c. Milkman's Node

5. Other virus diseases

a. Chikungunya

b. Infectious erythema

c. Unilateral laterothoracic rash

d. Roseola

e. Rubella

f. Measles

g. Gianotti-crosti syndrome 

Chapter 19. Sexually transmitted diseases 

1. Syphilis

2. Gonorrhea

3. Chancroid

4. Venereal lymphogranuloma

5. Inguinal granuloma 

Chapter 20. Infections by parasites 

1. Protozoa

a. Leishmaniasis

2. Helminths

a. Cutaneous Migrans Larva

b. Filariasis

3. Infestations

a. Scabiosis

b. Pediculosis

c. Tungiasis

d. Cutaneous myiasis 

III. NEOPLASTIC SKIN DISEASES 

Chapter 21. Benign neoplasms 

1. Benign epidermal tumors and proliferations

a. Seborrheic keratosis

b. Lichenoid Keratosis

c. Estucokeratosis

d. Poroqueratosis

e. Papular nigrans dermatosis

f. Verruciform Acrokeratosis

g. Cutaneous horn

h. Clear cell acanthoma

i. Acanthoma Acanthoma

j. Epidermolytic acanthoma

k. Large cell acanthoma

l. Inverted follicular keratosis

m. Epidermal nevus

n. Linear Verrucous Epidermal Nevus

o. Flegel disease (hyperkeratosis lenticularis perstans)

p. Comedogenic Nevus

q. Acanthosis nigricans

r. Confluent and cross-linked papillomatosis

s. Clear cell papulosis 

2. Cysts with stratified squamous epithelium

a. Epidermoid cyst

b. Winer's dilated pore and pillar sheath cliff

c. Millium Cyst

d. Triquilemal cyst

e. Proliferating epidermoid cyst

f. Cyst hair vellus

g. Steatocistoma

h. Keratocysts

i. Follicular Hybrid Cyst

j. Dermoid cyst

k. Pre-auricular cyst

l. Pilonidal cyst 

Chapter 22. Skin adnexal neoplasms

1. Hair follicle nevus
2. Trichofolliculoma
3. Sebaceous Nevus
4. Tricoepitelioma / tricoblastoma
5. Desmoplastic trichoepithelioma
6. Pilomatricoma
7. Pilmatrical carcinoma
8. Triquilemoma
9. Triquilemal Carcinoma
10. Tumor of the follicular infundibulum
11. Tricoadenoma
12. Proliferating pillar tumor
13. Sebaceous gland hyperplasite
14. Sebaceous adenoma-sebaceous epithelioma, sebaceoma
15. Sebaceous carcinoma
16. Syringoma
17. Poroma
18. Hydradenoma
19. Apocrine adenoma
20. Papilliferous Syringocystodenoma
21. Spiroadenoma
22. Cylindroma
23. Porocarcinoma
24. Ecrine Nevus
25. Sirigofibroadenoma
26. Papillary adenoma and adenocarcinoma 

Chapter 23. Muscle, adipose tissue and cartilaginous neoplasms 

1. Leiomyoma
2. Leiomyosarcoma

3. Smooth muscle hamartoma

4. Lipoma
5. Angiolipoma
6. Hibernoma
7. Superficial lipomatous nevus
8. Lipoblastoma
9. Liposarcoma
10. Chondrome 

Chapter 24. Vascular malformations 

1. Capillaries:

a. Klippel syndrome - Trenaunay

b. Porto wine stain

2. Arterial: Angiohistiocytoma

a. Telangiectasias

b. Cutist congenital telangiectatic marmorata

c. Angiokeratomas

3. Venous:

a. Venous Cephalic Malformation

b. Glomus-venous

4. Lymphatic: hemangiolinphangioma

5. Other vascular malformations:

a. Anemic nevus

b. Venous lake

c. Cherry anigoma

d. Telangiectatic granuloma

6. Infantile hemangioma 

Chapter 25. Fibrous and fibrohystiocytic proliferations of skin and tendons 

1. Dermatofibromas
2. Angiofibromas
3. Loose fibroma
4. Superficial fibromatosis: Juvenile plantar fibromatosis: Plantar fibromatosis Ledderhose disease
5. Acral fibrokeratoma
6. Superficial acral fibromxoma
7. Pleomorphic skin fibroma
8. Giant cell tumors of the tendon sheath
9. Tendon sheath fibroma
10. Nodular fasciitis
11. Connective tissue nevus
12. Children's digital fibroma
13. Childhood Myofibromatosis
14. Aponeurotic calcifying fibroma
15. Atypical fibroxanthoma
16. Dermatofibrosarcoma protuberans
17. Giant cell fibroblastoma 

Chapter 26. Congenital melanocytic nevus and acquired

1. Congenital melanocytic nevus
2. Acquired melanocytic nevus: union, compound, intradermal
3. Ungular matrix melanocytic nevus
4. Spilus nevus
5. Miescher's Nevus
6. Spitz nevus
7. Meyerson Nevus
8. Sutton nevus or halo nevus
9. Becker's Nevus
10. Dysplastic or Clark's Nevus
11. Blue nevus 

Chapter 27. Neural and neuroendocrine neoplasms

1. Neurofibroma
2 Neurothecoma
3. Schwanoma
4. Granular cell tumor
5. Perineuroma
6. Tumor of the malignant peripheral nerve sheath
7. Merkel cell carcinoma
8. Nasal glioma 

Chapter 28. Disorders of cells of langerháns and macrophages

1. Langerhans cell histiocytosis
2. Histiocytosis of non-Langerhans cells
3. Xanthomas 

Chapter 29. Malignant neoplasms

1. Actinic Keratosis
2. Adenoescamous carcinoma
3. Basal cell carcinoma
4. Basescamosal carcinoma
5. Keratoacanthoma
6. Bowen's disease
7. Queyrat Erythroplasia
8. Squamous cell carcinoma
9. Bowen's disease
10. Mastocytosis
11. Melanoma
12. Skin metastasis
13. Paget's disease 

14. T-cell Lymphoma

a. Lymphomatoid papulosis

b. Leukemia / T-cell lymphoma

c. Mycosis fungoides

d. Primary gamma / delta cutaneous T-cell lymphoma

e. CD8 positive aggressive epidermotropic cytotoxic T cell lymphoma

f. Nasal extraganglionic T / NK cell lymphoma

g. Paniculitis like T-cell lymphoma

15. B-cell Lymphoma

a. Primary cutaneous B-cell lymphoma of the marginal zone
b. Primary cutaneous central follicle lymphoma
c. Diffuse giant B-cell cutaneous lymphoma type leg
d. Intravascular diffuse giant B-cell lymphoma
e. B cell precursor lymphoblastic leukemia / lymphoma 

Chapter 30. Other lymphoproliferative disorders 

1. Plasmocytoid dendritic cell neoplasia
2. Jessner lymphocytic infiltrate
3. Lymphocytoma cutis
4. Extramedullary hematopoiesis
5. Leukemia complexion
6. Hodgkin's disease
7. Lymphomatoid granulomatosis

O autorze

Adriana Motta, MD

Dr. Motta is a dermatologist, professor and director of the dermatology program at the Universidad El Bosque, Bogotá, Colombia and chief of the dermatology department at Simón Bolivar Hospital, with a master’s degree in Higher Education. She is also a member of the Colombian Association of Dermatology and has more than 20 international and 10 national publications to her credit.

Luis Fernando González, MD

Dr. Luis Fernando Gonzalez trained at Los Andes University School of Medicine and completed his residency in dermatology at the Universidad El Bosque. He has authored several articles on clinical and surgical dermatology. Dr González is a member of the Colombian Association of Dermatology and Surgical Dermatology and the International Society of Dermatology. With expertise in clinical, surgical and aesthetic dermatology, he is currently engaged in private practice full time. 

Gonzalo García, MD

Dr. García is a dermatologist, professor and coordinator of the dermatology program at the Universidad El Bosque, Bogotá, Colombia, with master’s degrees in Higher Education and Marketing. Member of the Colombian Association of Dermatology and the American Academy of Dermatology.

Jennifer Guzmán, MD

Dr. Guzman received her dermatology degree from the Universidad El Bosque, Bogotá, Colombia in 2017, with a thesis on “The virtual Atlas of Dermatology: a tool for the learning of inflammatory, infectious and neoplasms skin diseases.”

She subsequently completed a 3-month observership in pediatric dermatology at the Hospital de Sant Pau in Barcelona, Spain. She is an active member of the Colombian Association of Dermatology and Surgical Dermatology, and member of the Ibero-Latin American College of Dermatology (CILAD). She is currently working as a clinical and surgical dermatologist for children and adults in the city of Medellin, Colombia. 

Lorena Prada, MD

Dr. Lorena Prada is a Colombian, board-certified dermatologist and a published author. She completed her medical degree at the Universidad Industrial de Santander in 2011, and her dermatology training in 2017. She received a merit award for her dissertation from the Universidad El Bosque. Dr Prada has presented papers nationally and was the recipient of a number of prizes at national dermatology meetings. Dr. Prada has a private practice in Bogotá. She regularly attends national and international conferences, courses and workshops.

Hugo Herrera, MD

Dr. Herrera is dermatologist, and completed his board certifications in dermatology in 1997. An active member of the Colombian Association of Dermatology and Surgical Dermatology, he has authored or co-authored several articles on dermatology and evidence-based guidelines for the management of skin cancer in Colombia. In addition, he teaches dermatology at the Universidad El Bosque, Bogotá, Colombia.

Mariam Rolón, MD

Dr. Rolón is a pathologist, dermatologist, dermatopathologist and pathologist-oncologist. She completed her board certifications as a pathologist in 1992, dermatologist in 1997, pathologist-oncologist in 2008, and dermatopathologist in 2013. She is an active member of the Colombian Association of Dermatology and Dermatopathology.

In addition, Dr. Rolón has authored or co-authored several articles on dermatology and evidence-based guidelines for the management of skin cancer. She currently teaches dermatopathology courses at the Universidad El Bosque, Bogotá, Colombia and at Los Andes University/ Fundacion Santa Fé University Hospital, Colombia.