Nom Ceneval Todas (1)

GUIA CENEVAL

NORMAS OFICIALES MEXICANAS ÍNDICE NOM 006 Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . PAG 1 NOM 010 VIH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PAG 18 NOM 014 CACU y Mama . . . . . . . . . . . . . . . . . . . . . . . . . . PAG 40 NOM 014 solo CACU (más nuevo) . . . . . . . . . . . . . . . . . . . PAG 52 NOM 017 Vigilancia Epidemiológica. . . . . . . . . . . . . . . . . . PAG 70 NOM 030 Hipertensión Arterial . . . . . . . . . . . . . . . . . . . . . . PAG 99 NOM 031 Atención del Niño . . . . . . . . . . . . . . . . . . . . . . . . PAG 128 NOM 037 Dislipidemias . . . . . . . . . . . . . . . . . . . . . . . . . . . PAG 187 NOM 168 Expediente Clínico . . . . . . . . . . . . . . . . . . . . . . . PAG 214 NOM 174 Obesidad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PAG 228 NOM 190 Violencia Familiar . . . . . . . . . . . . . . . . . . . . . . . PAG 237 NOM 007 Embarazo, Puerperio y RN . . . . . . . . . . . . . . . . PAG 253 NOM 015 Diabetes y Modificación . . . . . . . . . . . . . . .PAG 273 MOD p. 290 NOM 127 Potabilización del Agua y Modificación . . PAG 323 MOD p. 330

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PAG. 11

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./01/2 23/4/05

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PAG. 12

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PAG. 13

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PAG. 16

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SECRETARIA DE SALUD MODIFICACION a la Norma Oficial Mexicana NOM-014-SSA2-1994, Para la prevención, detección, diagnóstico, tratamiento, control y vigilancia epidemiológica del cáncer cérvico uterino. Al margen un sello con el Escudo Nacional, que dice: Estados Unidos Mexicanos.- Secretaría de Salud. MODIFICACION A LA NORMA OFICIAL MEXICANA NOM-014-SSA2-1994, PARA LA PREVENCION, DETECCION, DIAGNOSTICO, TRATAMIENTO, CONTROL Y VIGILANCIA EPIDEMIOLOGICA DEL CANCER CERVICO UTERINO.

MAURICIO HERNANDEZ AVILA, Subsecretario de Prevención y Promoción de la Salud y Presidente del Comité Consultivo Nacional de Normalización de Prevención y Control de Enfermedades, con fundamento en los artículos 39 de la Ley Orgánica de la Administración Pública Federal; 4o. de la Ley Federal de Procedimiento Administrativo; 3o. fracción XVIII, 13, apartado A), fracción I, 158, 159, 160 y 161 de la Ley General de Salud; 38 fracción II, 40 fracciones III y XI, 41, 43, 46, y 47 fracción IV, de la Ley Federal sobre Metrología y Normalización; 28 y 33 del Reglamento de la Ley Federal sobre Metrología y Normalización, y 8 fracciones V y XVI, 10 fracciones VII, XII y XVI, y 40 fracción II del Reglamento Interior de la Secretaría de Salud, he tenido a bien ordenar la publicación en el Diario Oficial de la Federación de la Modificación a la Norma Oficial Mexicana NOM-014-SSA2-1994, Para la prevención, detección, diagnóstico, tratamiento, control y vigilancia epidemiológica del cáncer cérvico uterino. CONSIDERANDO Que con fecha 5 de julio de 2005, en cumplimiento de lo previsto en el artículo 46 fracción I, de la Ley Federal sobre Metrología y Normalización, el Centro Nacional de Equidad de Género y Salud Reproductiva, presentó al Comité Consultivo Nacional de Normalización de Prevención y Control de Enfermedades, el anteproyecto de la presente Norma Oficial Mexicana. Que con fecha 18 de mayo de 2006, en cumplimiento del acuerdo del Comité y lo previsto en el artículo 47 fracción I, de la Ley Federal sobre Metrología y Normalización, se publicó en el Diario Oficial de la Federación el Proyecto de Norma, a efecto de que dentro de los siguientes sesenta días naturales posteriores a dicha publicación, los interesados presentaran sus comentarios al Comité Consultivo Nacional de Normalización de Prevención y Control de Enfermedades. Que con fecha previa, fueron publicados en el Diario Oficial de la Federación las respuestas a los comentarios recibidos por el mencionado Comité, en los términos del artículo 47 fracción III, de la Ley Federal sobre Metrología y Normalización. Que en atención a las anteriores consideraciones, contando con la aprobación del Comité Consultivo Nacional de Normalización de Prevención y Control de Enfermedades, se expide la siguiente: MODIFICACION A LA NORMA OFICIAL MEXICANA NOM-014-SSA2-1994, PARA LA PREVENCION, DETECCION, DIAGNOSTICO, TRATAMIENTO, CONTROL Y VIGILANCIA EPIDEMIOLOGICA DEL CANCER CERVICO UTERINO PREFACIO En la elaboración de esta Norma Oficial Mexicana, participaron las siguientes unidades administrativas e instituciones: Secretaría de Salud Centro Nacional de Equidad de Género y Salud Reproductiva Dirección General de Calidad y Educación en Salud Centro Nacional de Vigilancia Epidemiológica y Control de Enfermedades Centro Nacional para la Salud de la infancia y la Adolescencia Coordinación General de los Institutos Nacionales de Salud Hospital General de México Hospital Juárez de México Hospital General “Manuel Gea González” Hospital de la Mujer Instituto Nacional de Cancerología Instituto Nacional de Perinatología “Isidro Espinosa de los Reyes” Secretaría de Salud en el Estado de Nuevo León Instituto Nacional de Salud Pública Secretaría de la Defensa Nacional Dirección General de Sanidad Secretaría de Marina Dirección General de Sanidad Naval

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Instituto Mexicano del Seguro Social Coordinación General del Programa IMSS-Oportunidades Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado Petróleos Mexicanos Gerencia de Servicios Médicos Universidad Nacional Autónoma de México Universidad Autónoma de Nuevo León Academia Nacional de Medicina Academia Mexicana de Cirugía Academia Mexicana de Citopatología Asociación Mexicana de Ginecología y Obstetricia, A.C. Asociación Mexicana de Colposcopía y Patología Cervical, A.C. Federación Mexicana de Ginecología y Obstetricia, A.C. Asociación Mexicana de Obstetricia y Ginecología Infanto-Juvenil, A.C. Asociación Mexicana de Médicos Anatomopatólogos, A.C. Sociedad Mexicana de Oncología, A. C. Consejo Mexicano de Oncología, A.C. Colegio Mexicano de Colposcopistas Federación de Anatomía Patológica de la República Mexicana, A.C. Asociación Nacional de Lucha Contra el Cáncer INDICE 0.

Introducción

1.

Objetivo y campo de aplicación

2.

Referencias

3.

Definiciones y terminología

4.

Símbolos y abreviaturas

5.

Generalidades

6.

Consejería

7.

Prevención 7.1 Prevención primaria 7.1.1 Actividades de educación para la salud 7.1.2 Factores de riesgo 7.1.3 Actividades de Participación Social

8.

Detección oportuna 8.1 Los métodos de tamizaje para la detección oportuna 8.2 El resultado citológico se reportará de acuerdo con la Clasificación Bethesda

9.

Diagnóstico, tratamiento y control de las lesiones intraepiteliales 9.1 El examen colposcópico describirá las lesiones y el diagnóstico se notificará como sigue: 9.2 El resultado del estudio histopatológico debe ser informado de la siguiente manera:

10.

Diagnóstico, tratamiento y control del cáncer invasor

11.

Sistema de vigilancia epidemiológica

12.

De la capacitación y actualización del personal de salud profesional y técnico del nivel operativo

13.

Control de calidad

14.

Evaluación

15.

Apéndices

16.

Concordancia con normas o recomendaciones internacionales y normas mexicanas

17.

Bibliografía

18.

Observancia de la Norma

19.

Vigencia

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0. Introducción El cáncer cérvico uterino ocupa el primer lugar en incidencia causada por tumores malignos primero en mortalidad, relacionada con las neoplasias malignas en la población en general En la población femenina, el cáncer cérvico uterino es la primera causa de muerte por neoplasias malignas, particularmente en el grupo de 25 a 64 años de edad. En los países con programas de detección masiva adecuados a través del estudio citológico cervical, se ha observado una importante disminución de la mortalidad por cáncer cérvico uterino, atribuible a la detección de lesiones precursoras y preinvasoras, para las que el diagnóstico oportuno ofrece la posibilidad de tratamiento exitoso a un menor costo social y de servicios de salud. Se han resuelto muchas interrogantes sobre la etiología del cáncer cérvico uterino y actualmente se encuentran en desarrollo nuevas alternativas tanto de detección como terapéuticas y de prevención primaria (vacunas preventivas), que se irán incorporando de acuerdo a los estudios de costo efectividad que se realicen, para ofrecer un diagnóstico y tratamiento oportuno, eje fundamental del Programa de Prevención y Control del Cáncer Cérvico Uterino. Debido a la magnitud que muestra el cáncer cérvico uterino en nuestro país, se considera un problema de salud pública, por lo que es necesario subrayar como estrategia principal la coordinación de los sectores público, privado y social para afrontar este padecimiento con mayor compromiso, eficiencia y eficacia. Es importante lograr una participación activa de la comunidad en la solución de este problema de salud, la cual se podrá lograr mediante la educación para la salud, las acciones de promoción, difusión e información de los factores de riesgo, así como la concientización en el autocuidado de la salud. El beneficio que se espera obtener a través de esta Norma Oficial Mexicana es contribuir a la reducción de la morbilidad y mortalidad por Cáncer Cérvico Uterino. 1. Objetivo y campo de aplicación 1.1 Objetivo El objetivo de esta Norma es uniformar los principios, políticas, estrategias y criterios de operación para la prevención, diagnóstico, tratamiento, control y vigilancia epidemiológica del cáncer cérvico uterino. 1.2 Campo de aplicación Esta Norma es de observancia obligatoria para todo el personal de salud de los sectores público, social y privado que realiza acciones de prevención, detección, diagnóstico, tratamiento, control y vigilancia del cáncer cérvico uterino. Se deberá dar especial atención a las áreas rurales e indígenas y a las zonas urbano-marginadas, a través de estrategias de extensión de la cobertura. 2. Referencias Para la correcta aplicación de esta Norma es conveniente consultar: 2.1 Norma Oficial Mexicana NOM-017-SSA2-1994, para la vigilancia epidemiológica. 2.2 Norma Oficial Mexicana NOM-168-SSA1-1998, del expediente clínico. 3. Definiciones y terminología Para los fines de esta Norma son aplicables las siguientes definiciones y terminología: 3.1 Autopsia verbal: Estudio epidemiológico de caso que se realiza a través de la aplicación de cuestionarios a los familiares, para identificar los factores asociados a la defunción por cáncer cérvico uterino. 3.2 Biopsia: Proceso de extracción de tejidos u otras materias procedentes de un organismo vivo, para examen microscópico con fines de diagnóstico histopatológico. 3.3 Braquiterapia: Aplicación de fuentes radioactivas a corta distancia de la zona tumoral, con fines terapéuticos. 3.4 Cáncer: Tumor maligno originado por la pérdida de control del crecimiento de las células, que puede invadir estructuras adyacentes o propagarse a sitios alejados y tener como resultado la muerte. 3.5 Cáncer invasor: Cualquiera de las etapas de carcinoma invasivo, desde aquellos diagnosticados sólo por microscopio, hasta las lesiones de gran magnitud con invasión al estroma, extensión a todo el órgano, órganos adyacentes y propagación a órganos distantes. 3.6 Cáncer in situ: De acuerdo con la definición de la OMS, es una lesión en la que todo el epitelio o la mayor parte de él muestra el aspecto celular de carcinoma. No hay invasión del estroma subyacente.

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3.7 Cáncer microinvasor: Invasión del estroma cervical con una medida máxima de profundidad de 5 mm y una extensión horizontal máxima de 7 mm. 3.8 Captura de híbridos: Prueba biomolecular, basada en la amplificación de la señal de híbridos en solución, in vitro, para detectar blancos de DNA o RNA. 3.9 Carcinoma: Cáncer que se origina en los tejidos epiteliales. 3.10 Centro o Servicio oncológico: Area independiente o adscrita a una unidad hospitalaria, reservada para el diagnóstico y tratamiento de pacientes con afecciones debidas a lesiones precursoras o cáncer. 3.11 Cepillado endocervical: Obtención de células del canal endocervical a través de un cepillo, para su examen microscópico. 3.12 Ciclo pélvico: Aplicación seriada de radiaciones dirigidas al área pélvica, con fines de tratamiento. 3.13 Cirugía derivativa: Se dice de aquella cirugía que se realiza a fin de permitir el paso de fluidos corporales, eludiendo obstrucciones existentes (tumorales entre otros) y que modifica el paso anatomo-funcional normal (Ej. vejiga ileal, colostomía, entre otros). 3.14 Citología cervical: Estudio que se realiza mediante la observación y análisis de una muestra de células del endocérvix y exocérvix a través de un microscopio, para determinar cambios o alteraciones en la anatomía y fisiología de las células. También conocida como Prueba de Papanicolaou. 3.15 Colposcopía: Procedimiento exploratorio instrumentado estereoscópico, en el que se emplea un aparato con sistemas ópticos de aumento, a través del cual se puede observar el tracto genital inferior y ano, visualizándose las condiciones de su epitelio y al cual se le pueden aplicar distintas sustancias como solución fisiológica, ácido acético diluido, yodo Lugol u otras con fines de orientación diagnóstica. 3.16 Colposcopía no satisfactoria: Una colposcopía es no satisfactoria cuando no se puede visualizar la unión escamo-columnar o los límites de la lesión en el cuello uterino. 3.17 Consentimiento Informado: Es la aceptación libre, voluntaria, con pleno conocimiento y comprensión de la información por la usuaria para que le realicen un procedimiento diagnóstico o terapéutico. 3.18 Conización: Resección de la zona de transformación del cuello uterino con una profundidad no menor a 5 mm con fines diagnósticos y/o terapéuticos. También se denomina cilindro o cono diagnóstico. 3.19 Consejería: Proceso de información y comunicación entre el prestador de servicios y la usuaria. 3.20 Criocirugía: Aplicación de baja temperatura a un tejido hasta alcanzar el punto de congelación del agua intracelular produciendo la muerte celular. 3.21 Displasia: Pérdida de la capacidad de maduración del epitelio, con alteraciones en la morfología de sus componentes celulares. 3.22 Electrocirugía: Empleo de la corriente eléctrica alterna de alta frecuencia para escindir la zona de transformación y la lesión con una profundidad no menor de 5 mm. 3.23 Factor de riesgo: Condición particular que incrementa la posibilidad de desarrollar una patología. 3.24 Histerectomía: Intervención quirúrgica para extirpar totalmente el útero por vía vaginal o abdominal. 3.25 Histerectomía extrafascial: Extirpación quirúrgica del útero por fuera de su fascia. 3.26 Histopatología: Estudio macroscópico y microscópico de las alteraciones en los tejidos y órganos extirpados. 3.27 Incidencia: Número de casos nuevos de una enfermedad o daño, ocurridos en una población, lugar y tiempo determinados. 3.28 LASER (Light Amplification Stimulated Emission of Radiation): Uso de la energía fotónica para la destrucción o escisión de lesiones y/o la zona de transformación del cuello uterino con una profundidad no menor a 5 mm. 3.29 Legrado endocervical: Procedimiento diagnóstico instrumentado mediante el cual se obtiene una muestra representativa del epitelio endocervical, para determinar grado o extensión de la lesión exocervical o endocervical. 3.30 Lesión escamosa intraepitelial de bajo grado (LEIBG): Incluye los cambios celulares asociados al efecto citopático de la infección por virus del papiloma humano (conocida como atipia coilocítica), restringida generalmente a las capas superficiales. Se incluye en estas lesiones a la displasia leve/ NIC 1.

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3.31 Lesión escamosa intraepitelial de alto grado (LEIAG): Cambios celulares que abarcan dos tercios o más del espesor del epitelio escamoso. Corresponden a este tipo de lesiones las identificadas como displasia moderada, grave y cáncer in situ/ NIC 2-3. 3.32 Linfadenectomía: Procedimiento quirúrgico mediante el cual se extirpan ganglios linfáticos, con fines diagnóstico-terapéuticos 3.33 Melanoma: Cáncer, generalmente fatal, que se origina de los melanocitos de la piel. 3.34 Morbilidad, Tasa de: la que tiene como numerador el número de enfermos en una población determinada durante un período y lugar específico y el denominador representa la población donde ocurrieron los casos. Se expresa como una tasa, puede ser general o específica. 3.35 Mortalidad, Tasa de: la que tiene como numerador el total de defunciones producidas en una población en un periodo de tiempo determinado y el denominador representa la población donde ocurrieron las muertes. Se expresa como una tasa, puede ser general o específica. 3.36 Neoplasia: Proliferación autónoma de células anormales. 3.37 Pruebas biomoleculares (Captura de Híbridos y RPC): Métodos de diagnóstico por laboratorio, para la detección del genoma de agentes infecciosos como el virus del papiloma humano. 3.38 RPC: (Reacción de la Polimerasa en Cadena): Prueba biomolecular en la que el DNA blanco se amplifica selectivamente por medios enzimáticos, a través de ciclos repetidos de desnaturalización, hibridación del fragmento precursor y extensión de éste. 3.39 Sistema de Clasificación Bethesda: Nomenclatura sobre los lineamientos para el reporte de resultados de la citología cervical. 3.40 Tamizaje: Prueba de detección masiva realizada de manera intencionada con el objeto de identificar oportunamente individuos con una enfermedad o trastorno de salud específico. 3.41 Tratamiento conservador: Es aquel que permite eliminar o destruir el tejido lesionado manteniendo el resto del órgano y sus funciones sin cambio. Los tratamientos conservadores en colposcopía son la electrocirugía, la criocirugía y la laserterapia. 3.42 Vigilancia Epidemiológica: Conjunto de acciones en las que participan diferentes instituciones públicas y privadas del Sistema Nacional de Salud, para conocer de manera oportuna y uniforme la distribución de las enfermedades en una población determinada. 3.43 Virus del Papiloma Humano: Microorganismos pertenecientes a la familia de los Papillomaviridae, infectan la piel y las mucosas pudiendo producir tumores epiteliales benignos o malignos, varían en su tropismo tisular, su asociación con distintas lesiones y su potencial oncogénico. 3.44 Visualización Directa: Inspección del cérvix mediante el uso de un espejo vaginal y una iluminación apropiada. 3.45 Zona de transformación: Es el área comprendida entre el epitelio escamoso original y el epitelio columnar del cérvix uterino, dentro de la cual pueden identificarse diversos grados de maduración del epitelio metaplásico. 4. Símbolos y abreviaturas 4.1 ASC: Anormalidades en el epitelio plano (deriva de la terminología internacional, por sus iniciales en inglés: Atypical Squamous Cell) 4.2 ASC-H Anormalidades en el epitelio plano, probablemente de alto grado (deriva de la terminología internacional, por sus iniciales en inglés: Atypical Squamous Cell, High grade) 4.3 CONAVE: Comité Nacional de Vigilancia Epidemiológica 4.4 InDRE: Instituto de Diagnóstico y Referencias Epidemiológicos, Secretaría de Salud 4.5 LASER: Light Amplification Stimulated Emission of Radiation 4.6 LEIBG: Lesión Escamosa Intraepitelial de Bajo Grado 4.7 LEIAG: Lesión Escamosa Intraepitelial de Alto Grado 4.8 NIC: Neoplasia Intraepitelial Cervical 4.9 NOM: Norma Oficial Mexicana 4.10 OMS: Organización Mundial de la Salud

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4.11 OPS: Organización Panamericana de la Salud 4.12 RPC: Reacción de la Polimerasa en Cadena 4.13 VPH: Virus del Papiloma Humano 4.14 SINAVE: Sistema Nacional de Vigilancia Epidemiológica 4.15 SICAM-Procacu: Sistema Integral del Cáncer en la Mujer 5. Generalidades 5.1 La orientación-consejería se otorgará a toda mujer que solicite por primera vez la prueba de detección y/o que tenga un resultado positivo a LEIBG, LEIAG o cáncer. 5.2 La prevención primaria y secundaria se llevará a cabo por medio de la vacunación y de la citología cervical, respectivamente, éstas serán gratuitas en las unidades médicas de las instituciones públicas del Sistema Nacional de Salud. 5.3 Las mujeres con reporte citológico de lesión de bajo y alto grado, deberán referirse a una clínica de colposcopía. 5.4. El diagnóstico presuntivo de cáncer cérvico uterino se puede establecer por examen clínico, citología de cuello o colposcopía. El diagnóstico definitivo, se establece únicamente con el examen histopatológico por medio de biopsia dirigida o pieza quirúrgica. 5.5 El cáncer de cuello del útero se codificará con fines estadísticos de acuerdo con la décima revisión Internacional de la Clasificación Internacional de Enfermedades (OMS-OPS) tal y como se indica a continuación: 5.5.1 Displasias N87

Displasia de cuello uterino Excluye: carcinoma in situ del cuello del útero (DO6)

N87.0

Displasia cervical leve Neoplasia Intraepitelial cervical (NIC), grado l

N87.1

Displasia cervical moderada. Neoplasia intraepitelial cervical (NIC), grado ll

N87.2

Displasia cervical severa, no clasificada en otra parte Displasia cervical severa SAI Excluye: Neoplasia intraepitelial Cervical (NIC), grado III, con o sin mención de displasia severa (D06)

N87.9

Displasia del cuello del útero, no especificada

5.5.2 Carcinoma in situ del cuello uterino D06

Carcinoma in situ del cuello del útero. Incluye: Neoplasia intraepitelial cervical (NIC), grado III, con o sin mención de displasia severa. Excluye: Displasia severa del cuello SAl (N87.2) Melanoma in situ del cuello (D03.5)

D06.0

Carcinoma in situ del endocérvix

D06.1

Carcinoma in situ del exocérvix

D06.7

Carcinoma in situ de otras partes especificadas del cuello del útero.

D06.9

Carcinoma in situ del cuello del útero, parte no especificada.

5.5.3 Tumor maligno de cuello de útero C53

Tumor maligno de cuello de útero

C53.0

Tumor maligno de endocérvix

C53.1

Tumor maligno de exocérvix

C53.8

Lesión de sitios contiguos del cuello del útero.

C53.9

Tumor maligno de cuello de útero, sin otra especificación.

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5.6 Las instituciones públicas del Sistema Nacional de Salud cuentan con sistemas de información, supervisión y evaluación que permiten verificar la aplicación, difusión y conocimiento de la Norma; en las instituciones privadas, la verificación será realizada por la Secretaría de Salud. 6. Consejería 6.1 La consejería se considera parte importante del proceso de comunicación y análisis entre el prestador de servicios y la usuaria, por lo que toda consulta derivada del Programa de Cáncer Cérvico Uterino debe ir acompañada de la consejería como una acción primordial. 6.2 Mediante la consejería se debe proporcionar información, orientación, asesoría y aclarar dudas a la mujer y sus familiares, tomando como referencia lo establecido en esta Norma en materia de prevención, pruebas de detección, diagnóstico y tratamiento de las lesiones de bajo y alto grado y del cáncer cérvico uterino. 6.3 La consejería debe explorar la expresión de sentimientos de la mujer como angustia, temor, ambivalencia, depresión, ira y negación como parte integral de la atención médica. 6.4 La consejería debe hacer énfasis en la efectividad y limitaciones que tienen la detección oportuna, el diagnóstico y el tratamiento, considerando la particularidad de cada caso. Es importante enfatizar en la responsabilidad compartida de la mujer con el personal de salud en el éxito del tratamiento a través de su participación activa. 6.5 Por medio de la consejería se debe garantizar a la mujer y a sus familiares el carácter privado y confidencial de la información que proporcione para favorecer la comunicación con absoluta confianza y libertad. 6.6 Mediante la consejería, se debe asegurar que la decisión de realizarse la citología cervical sea libre, informada y basada en los principios de respeto, voluntariedad e imparcialidad de la orientación y se debe enfatizar que la toma de decisión sobre el tratamiento sea apoyada en el consentimiento informado. 6.6.1 Mediante la consejería se asesorará a los padres o tutores de mujeres menores de edad, sobre de las vacunas profilácticas para la infección por el VPH. 6.7 La consejería debe ser proporcionada por personal de salud que haya recibido capacitación específica y debe estar ampliamente informado sobre la prevención, detección y tratamiento de las lesiones precursoras y cáncer cérvico uterino. 6.8 La consejería debe impartirse en las diferentes oportunidades de consulta o visita que la usuaria haga al personal de salud o al servicio. 6.8.1 Se debe tener especial interés en proporcionar consejería a mujeres que: - Nunca se hayan realizado la detección - Presenten los factores de riesgo asociados a cáncer cérvico uterino - Acudan a la clínica de colposcopía - Tengan hijas menores de edad - No hayan iniciado vida sexual 7. Prevención La prevención del cáncer cérvico uterino se realizará por medio de la promoción de la salud, la vacunación y la detección oportuna, orientadas a evitar o disminuir los factores de riesgo y a descubrir oportunamente lesiones precursoras. 7.1 Prevención Primaria La prevención primaria establece premisas de educación en salud para reducir conductas sexuales de alto riesgo e incluye el uso del condón, promoción de relaciones sexuales monogámicas y el uso de las vacunas profilácticas contra los VPH´s asociados más frecuentemente al cáncer cérvico uterino. El uso, aplicación, dosis, indicaciones y periodicidad serán establecidos de acuerdo a la NOM-36-SSA2-2002. 7.1.1 Actividades de Educación para la Salud El personal de salud deberá: - Informar a la población en general sobre la importancia de la enfermedad, los factores de riesgo y las posibilidades de prevención, diagnóstico y de tratamiento oportuno.

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- Alentar la demanda de atención médica oportuna, periódica y de calidad para la detección y/o tratamiento, garantizando la información suficiente para la usuaria acerca de los procedimientos, con el consentimiento informado por escrito, en los casos de tratamiento quirúrgico que señalan los artículos 80 y 81 del Reglamento de la Ley General de Salud en Materia de Prestación de Servicios de Atención Médica. - Promover las acciones de detección oportuna y tratamiento. - Orientar a las mujeres y hombres sobre su compromiso en el autocuidado de la salud y sobre su participación en los factores de riesgo de la enfermedad. 7.1.2 Factores de riesgo: - Mujeres de 25 a 64 años de edad. - Inicio de relaciones sexuales antes de los 18 años. - Antecedentes de enfermedades de transmisión sexual. - Infección cérvico vaginal por virus del papiloma humano. - Múltiples parejas sexuales (del hombre y de la mujer). - Tabaquismo. - Desnutrición. - Deficiencia de antioxidantes. - Pacientes con inmuno-deficiencias. - NUNCA HABERSE PRACTICADO EL ESTUDIO CITOLOGICO 7.1.3 Actividades de Participación Social El personal de salud deberá: - Promover la participación de grupos organizados y líderes de la comunidad para que actúen como informadores y promotores ante su núcleo de influencia. - Integrar a la población femenina de las asociaciones, agrupaciones gremiales, centros laborales, asociaciones de profesionales del campo de la salud y del campo de la comunicación, así como asociaciones de la sociedad civil, a que participen en las acciones intensivas y permanentes de detección oportuna de cáncer cérvico uterino. - Capacitar a promotores institucionales y voluntarios, de acuerdo con los lineamientos de esta Norma. 8. Detección oportuna 8.1 Los métodos de tamizaje para la detección oportuna de cáncer del cuello uterino son: Citología Cervical y Visualización Directa con Acido Acético (sólo cuando no se cuente con infraestructura para realizar la citología cervical). Las pruebas biomoleculares como Captura de Híbridos y RPC, pueden ser utilizadas como complemento de la citología. 8.1.1 El personal de salud de primer contacto (médicos, enfermeras y técnicos capacitados) ofrecerá a toda mujer entre 25 a 64 años de edad, en especial a aquellas con factores de riesgo, la prueba de detección del cáncer cérvico-uterino y se le realizará a quien la solicite independientemente de su edad. 8.2 Las mujeres con muestra citológica inadecuada para el diagnóstico, deberán ser localizadas en un lapso no mayor a 4 semanas, para repetir la prueba. 8.2.1 En mujeres con dos citologías anuales consecutivas con resultado negativo a lesión intraepitelial o cáncer, se realizará la detección cada 3 años. 8.2.2 A las mujeres con resultado citológico de lesión intraepitelial o cáncer, se les informará que el resultado no es concluyente y que requieren el diagnóstico confirmatorio. Estas pacientes serán enviadas a una clínica de colposcopía. Cuando sean dadas de alta, continuarán con el control citológico establecido. 8.3 El resultado citológico se reportará de acuerdo con el Sistema de Clasificación Bethesda, como se indica a continuación: I. Calidad de la muestra: A.- Adecuada 1.- Presencia de células de la zona de transformación

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2.- Ausencia de células de la zona de transformación 3.- 50-75% de hemorragia, inflamación, necrosis y/o artificios B.- Inadecuada 1.- Por artificios, inflamación, hemorragia y/o necrosis en más del 75% del extendido 2.- Información clínica insuficiente 3.- Laminillas rotas o mal identificadas, otros II. Interpretación/ Resultado A.- Negativo para lesión intraepitelial y/o maligno 1.- Organismos: a.- Trichomonas Vaginalis b.- Micro-organismos micóticos, morfológicamente compatibles con Cándida sp. c.- Cambio en la flora sugestiva de vaginosis bacteriana d- Micro-organismos morfológicamente compatibles con Actinomyces sp. e.- Cambios celulares compatibles con infección por Virus del Herpes Simple 2.- Cambios celulares reactivos asociados a: a.- Inflamación (incluye reparación atípica) b.- Radioterapia c.- Dispositivo intrauterino d.- Células glandulares post- histerectomía e.- Atrofia B.- Anormalidades en epitelio plano/escamoso 1.- Anormalidades en el epitelio plano (ASC) 1.1 Células escamosas atípicas de significado indeterminado (ASC-US) 1.2 Células escamosas atípicas, no se puede descartar lesión intraepitelial escamosa de alto grado (ASC-H) 2.- Lesión intraepitelial de bajo grado (VPH, displasia leve, NIC I) 3.- Lesión intraepitelial de alto grado (displasia moderada, displasia severa, carcinoma in situ, NIC2, NIC3) 4.- Carcinoma epidermoide C.- Anormalidades en epitelio glandular 1.- Células glandulares endocervicales atípicas (AGC) 2.- Células glandulares endometriales atípicas 3.- Células glandulares atípicas 4.- Adenocarcinoma in situ 5.- Adenocarcinoma D.- Otros 1.- Presencia de células endometriales (no atípicas) en mujeres de 40 años o mayores. 8.4 Toda mujer debe ser informada de su resultado citológico en menos de cuatro semanas a partir de la fecha de la toma de la muestra. 9. Diagnóstico, tratamiento y control de las lesiones intraepiteliales. 9.1 El diagnóstico presuncional de lesión intraepitelial se puede establecer por citología o colposcopía de cuello uterino y el de cáncer invasor por examen clínico, además de los anteriores. 9.1.1 El diagnóstico definitivo se establece únicamente por examen histopatológico.

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9.2 El examen colposcópico describirá las lesiones y el diagnóstico se notificará como sigue: 1.

Sin alteraciones

2.

Alteraciones inflamatorias inespecíficas

3.

Lesión intraepitelial de bajo grado

4.

Lesión intraepitelial de alto grado

5.

Lesiones sugestivas de invasión

6.

Cáncer invasor

7.

Otros hallazgos (condilomas, queratosis, erosión, inflamación, atrofia, deciduosis, pólipo)

9.3 El resultado del estudio histopatológico debe ser informado de la siguiente manera: A.

Insuficiente o inadecuado para el diagnóstico

B.

Tejido de cérvix sin alteraciones histológicas significativas

C.

Cervicitis aguda o crónica

D.

Lesión intraepitelial escamosa de bajo grado (VPH, NIC 1 o displasia leve)

E. Lesión intraepitelial escamosa de alto grado (NIC 2 o displasia moderada, NIC 3 o displasia grave y cáncer in situ) F.

Carcinoma epidermoide microinvasor

G.

Carcinoma epidermoide invasor

H.

Adenocarcinoma endocervical in situ

I.

Adenocarcinoma endocervical invasor

J.

Adenocarcinoma endometrial invasor

K.

Sarcoma

L.

Tumor maligno no especificado

M.

Otros (especificar)

9.4 El médico citopatólogo, citólogo y/o patólogo, debe avalar mediante su nombre y firma el 100% de las cédulas de resultados de casos positivos de cáncer y lesiones intraepiteliales de bajo y alto grado. 9.5 El personal médico establecerá el tratamiento correspondiente en la unidad médica de atención, a aquellas pacientes cuyo resultado citológico reporte la presencia de procesos infecciosos. Posteriormente, después de dos citologías anuales consecutivas negativas a LEIBG, LEIAG o cáncer, el control citológico se realizará cada tres años. 9.5.1 Las pacientes referidas a una clínica de colposcopía o bien, a un Centro o Servicio Oncológico, además de su hoja de referencia, deberán contar con notas médicas en el expediente de la unidad del primer nivel o en el de la clínica de colposcopía, según corresponda, que permitan conocer sus condiciones y su evolución, incluyendo tratamientos. En caso de contrarreferencia, ésta deberá acompañarse de su respectiva nota médica. 9.5.2 Las pacientes a quienes se les realizó citología cervical, cuyo resultado es LEIBG (infección por VPH, displasia leve o NIC 1); LEIAG (displasia moderada y grave o NIC 2 y 3) o cáncer deben enviarse a una clínica de colposcopía, para realizar estudio colposcópico. 9.5.3 Si el resultado de la citología es LEIBG, la colposcopía es satisfactoria y sin evidencia de LEIBG, se realizará control citológico en un año (Apéndice Normativo A) 9.5.4 Si la citología es de LEIBG, la colposcopía es satisfactoria y existe evidencia de lesión, se debe tomar una biopsia dirigida. 9.5.4.1 Si la biopsia dirigida es negativa, se realizará nueva colposcopía para verificar el diagnóstico y en caso necesario, tomar nueva biopsia dirigida y revalorar. 9.5.4.2 Si la biopsia dirigida es reportada como LEIBG se podrá dar tratamiento conservador: criocirugía, electrocirugía o laserterapia (sólo si cumple con las condiciones referidas en el Apéndice 1) o se podrá mantener a la paciente en vigilancia en la clínica de colposcopía, con colposcopía y estudio citológico cada seis meses, durante 24 meses.

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9.5.4.3 Si la biopsia dirigida es reportada como LEIAG (Lesión Intraepitelial Escamosa de Alto Grado) se realizará tratamiento conservador (electrocirugía o laserterapia). En las mujeres posmenopáusicas, dependiendo de las condiciones anatómicas del cérvix, se realizará tratamiento conservador en la clínica de colposcopía o tratamiento quirúrgico (histerectomía extrafascial) en el servicio que corresponda. 9.5.4.4 Si la biopsia dirigida reporta cáncer microinvasor o invasor, la paciente se transferirá a un Servicio o Centro Oncológico para su tratamiento correspondiente. 9.5.4.5 Si la citología reporta LEIBG y la colposcopía es no satisfactoria, se tomará cepillado endocervical (Apéndice Normativo A) 9.6 En caso de colposcopía no satisfactoria, negativa a LEIBG y con cepillado endocervical negativo, se continuará su control en la clínica de colposcopía en seis meses, con colposcopía y citología. 9.6.1.1 Si el cepillado endocervical reporta LEIBG se tratará a la paciente como LEIAG, con métodos conservadores escisionales. 9.6.1.2 Si el cepillado endocervical es reportado como LEIAG, se tratará en la clínica de colposcopía. Si el cepillado reporta cáncer microinvasor o invasor, se referirá a un Servicio o Centro Oncológico (Apéndice Normativo A) 9.6.2 Las pacientes con resultado citológico de LEIAG se transferirán a una clínica de colposcopía para su examen colposcópico (Apéndice Normativo B) 9.6.2.1 Si la citología reporta LEIAG, la colposcopía es satisfactoria y sin evidencia de lesión, se realizará revaloración del caso, tomando una nueva citología a los tres meses. Si todos los resultados son negativos la paciente continuará su control en la clínica de colposcopía con citología y colposcopía semestrales durante dos años; de persistir las mismas condiciones, se valorará el envío a su unidad médica de primer nivel para que continúe su control con citología anual (Apéndice Normativo B) 9.6.2.2 Si la citología reporta LEIAG y la colposcopía es satisfactoria con evidencia de lesión, se realizará biopsia dirigida. 9.6.2.3 Si la biopsia es negativa y ante lesión evidente, se solicitará revisión del diagnóstico histopatológico y se realizará nueva colposcopía y cepillado endocervical para verificar el diagnóstico colposcópico y en caso necesario, tomar nueva biopsia dirigida. 9.6.2.4 En caso de que la biopsia y el cepillado endocervical resultaran nuevamente negativos, se continuará su control con citología y colposcopía anual. 9.6.2.5 Si la biopsia dirigida es reportada como LEIBG, se dará tratamiento conservador o se podrá mantener a la paciente en vigilancia en la clínica de colposcopía cada seis meses por 24 meses, con colposcopía y estudio citológico y revalorar el caso. 9.6.2.6 En caso de biopsia positiva a LEIAG, se debe realizar tratamiento conservador (electrocirugía o laserterapia) de acuerdo a la disponibilidad de cada institución y, a juicio del colposcopista. 9.6.2.7 Si la biopsia dirigida es reportada como cáncer microinvasor o invasor, referir a un Servicio o Centro Oncológico. 9.6.3 Si la citología es LEIAG y la colposcopía no es satisfactoria, tomar cepillado endocervical. 9.6.3.1 Si el cepillado endocervical es negativo, con el resultado revalorar el caso lo más pronto posible. 9.6.3.2 Si el cepillado endocervical señala LEIBG, se tratará a la paciente como LEIAG, con métodos conservadores escisionales y revalorar con resultado histopatológico. 9.6.3.3 Si el cepillado endocervical señala LEIAG, se realizará conización (cilindro o cono diagnóstico) y revalorar. 9.6.3.4 De acuerdo a la revaloración, se decidirá si la paciente permanece en control en la clínica de colposcopía o si es necesario referirla. 9.6.3.5 Si la colposcopía es no satisfactoria y el cepillado reporta cáncer invasor, se referirá a un Servicio o Centro Oncológico. 9.7 Las pacientes con citología de cáncer cérvico uterino invasor pasarán a la clínica de colposcopía para su estudio. (Apéndice Normativo C) 9.7.1 Si la colposcopía muestra tumor macroscópico, se realizará biopsia dirigida y una cuidadosa evaluación de la extensión de la neoplasia.

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9.7.1.2 Si la biopsia confirma el diagnóstico de cáncer invasor, la paciente será referida a un Servicio o Centro Oncológico. 9.7.1.3 Si la citología es de cáncer invasor, la colposcopía es satisfactoria y se encuentra otro tipo de lesión, se tomará biopsia dirigida. 9.7.1.4 Si el resultado de la biopsia es cáncer invasor o cáncer microinvasor, la paciente será referida a un Servicio o Centro Oncológico. 9.7.2. Si el resultado de la biopsia es LEIBG, se realizará manejo como si fuera LEIAG, con tratamiento conservador. 9.7.2.1 Si el resultado de la biopsia es LEIAG, deberá tratarse en la Clínica de Colposcopía. 9.7.3 Si la colposcopía no es satisfactoria, tomar cepillado o legrado endocervical. Si resulta positivo (LEIBG, LEIAG, o cáncer invasor), se referirá a la paciente a una unidad que cuente con quirófano para la realización de un cono con bisturí. 9.7.3.1 Si el cepillado endocervical y la biopsia son negativos, se revalorará el caso lo más pronto posible. 9.7.3.2 De acuerdo a la revaloración, se decidirá si la paciente permanece en control en la clínica de colposcopía o si es necesario referirla. 9.8 Las pacientes embarazadas que presenten citología con LEIBG, LEIAG y cáncer invasor, pasarán a la clínica de colposcopía para su estudio (Apéndice Normativo D). 9.8.1 Si no existe lesión, la paciente se revalorará a las 12 semanas del nacimiento del producto. Pacientes con citología de cáncer invasor serán enviadas a un Servicio o Centro Oncológico. 9.8.2 Cuando se tenga la confirmación histopatológica de LEIBG y LEIAG, las pacientes embarazadas permanecerán en vigilancia con citología y colposcopía cada doce semanas y se programará su revaloración a las doce semanas de ocurrido el nacimiento del producto. 9.8.3 El tratamiento que se aplicará a las pacientes embarazadas con cáncer invasor será de acuerdo a: - Etapa clínica - Valoración perinatológica - Tipo histopatológico - Opinión de la paciente - Comité de ética 9.8.4 Si el resultado histopatológico es de cáncer microinvasor o invasor, la paciente será referida a un Servicio o Centro Oncológico, en el que será evaluada por el Comité de Etica de la institución (pública o privada) y tratada de acuerdo a los rubros mencionados en el numeral 9.8.3. 10. Diagnóstico, tratamiento y control del cáncer invasor 10.1 Clasificación clínica de acuerdo con el Sistema de la Federación Internacional de Ginecología y Obstetricia. 10.1.1 El cáncer microinvasor IA1 se trata electivamente con histerectomía extrafascial, con margen de vagina de 2 cm. (Clase I) 10.1.1.2 Paciente para quien existe contraindicación quirúrgica, será considerada para tratamiento con braquiterapia. 10.1.2 Pacientes con paridad no satisfecha con diagnóstico de cáncer invasor y con posibilidad de vigilancia estrecha, serán valoradas para establecer un tratamiento que preserve su fertilidad. 10.1.3 El cáncer microinvasor IA2 se trata electivamente con histerectomía extrafascial Clase I o Clase II. 10.1.3.1 En presencia de factores histopatológicos de mal pronóstico se realizará linfadenectomía pélvica. 10.1.3.2 Paciente para quien existe contraindicación quirúrgica, será considerada para tratamiento con radioterapia. 10.1.4 El estadio IB1 y el IIA menor de 4 cm, se trata con histerectomía clase III o ciclo pélvico con radioterapia. 10.1.4.1 Pacientes tratadas con cirugía o con factores pronósticos adversos, recibirán tratamiento adyuvante de radioterapia con o sin quimioterapia simultánea mediante esquemas con Platino.

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10.1.5 El estadio IB2 y los estadios II voluminosos se tratan con radioterapia o con la combinación de radioterapia y quimioterapia simultáneas mediante esquemas con Platino. La decisión para utilizar esta combinación se tomará de acuerdo a las características de cada caso y teniendo en cuenta los protocolos de tratamiento de cada institución. 10.1.6 Los estadios II no considerados en el inciso previo y los III y IVA, se tratan con radioterapia. La decisión para utilizar la combinación simultánea, se tomará de acuerdo a las características de cada caso. En presencia de fístulas se realizará cirugía derivativa, previa a la radioterapia. 10.1.7 El estadio IVB se trata individualmente de acuerdo a las manifestaciones predominantes de cada paciente. 10.2 El cáncer cérvico uterino recurrente posterior a cirugía se trata con radioterapia. 10.2.1 El cáncer cérvico uterino persistente o recurrente a radioterapia con tumor limitado a la pelvis, será considerado para cirugía de rescate (excenteración pélvica) 10.2.2 Neoplasias no controladas con los procedimientos terapéuticos convencionales, serán consideradas individualmente para manejo paliativo. 11. Sistema de vigilancia epidemiológica 11.1 El sistema establece el registro sistemático de resultados del tamizaje de LEIBG, LEIAG, cáncer in situ y cáncer invasor en los establecimientos de prestación de servicios de atención médica. Para la vigilancia epidemiológica de cáncer cérvico uterino establece la búsqueda intencionada de los casos sujetos a estudio (casos y defunciones) por los establecimientos de prestación de servicios de atención médica. 11.2 Requieren ser objeto de estudio epidemiológico los casos probables y confirmados de lesiones intraepiteliales de bajo y alto grado, así como los de cáncer microinvasor, invasor, adenocarcinoma y tumor maligno no especificado. 11.3 El personal de salud responsable de cada área, llenará los siguientes formatos: Solicitud y Reporte de Resultados de Citología, Seguimiento de Casos, Reporte Mensual de Detecciones de Cáncer Cérvico Uterino y Reporte de Colposcopía y de Histopatología, en todas las instituciones de salud. 11.4 La vigilancia epidemiológica del virus de papiloma humano se hará por medio del registro de los estudios citológicos e histopatológicos con diagnóstico de cambios citopáticos sugestivos de la infección. 11.5 El personal de salud deberá realizar el registro de los casos de LEIBG, LEIAG y cáncer microinvasor e invasor. 11.6 Cada institución informará de los casos de cáncer cérvico uterino ocurridos en las diferentes áreas de atención de conformidad con los mecanismos establecidos para cada institución en el CONAVE y en los sistemas de información vigentes. 11.7 El informe de seguimiento de los casos (lesiones intraepiteliales de alto y bajo grado, cáncer microinvasor e invasor) se llevará a cabo en forma trimestral, bajo los lineamientos establecidos en la Norma Oficial Mexicana NOM-017-SSA2-1994. 11.8 La autoridad sanitaria es la responsable de revisar como mínimo el 50% de los certificados de defunción que indiquen al cáncer cérvico uterino como causa básica o asociada del fallecimiento; dicha revisión la hará el Responsable Estatal y el Jurisdiccional o Regional (según corresponda en cada institución del sector salud) de cáncer cérvico uterino, al término de lo cual enviará la información completa al nivel estatal y éste a su vez al nivel nacional. 11.8.1 El Personal Responsable de la Unidad Médica (o alguna persona asignada) realizará las autopsias verbales del 50% como mínimo, de las defunciones debidas al cáncer cérvico uterino, ya fuera como causa básica o asociada. 12. De la capacitación y actualización del personal de salud profesional y técnico del nivel operativo 12.1 Para garantizar un servicio de calidad del personal de salud que realiza actividades de prevención, detección, diagnóstico, tratamiento, control y vigilancia epidemiológica de cáncer cérvico uterino de las instituciones públicas, se llevarán a cabo actividades de capacitación y actualización de dicho personal apegándose a lo establecido en el “Programa Unico de Capacitación y Actualización para médicos generales, especialistas, citopatólogos y citotecnólogos”, con la periodicidad que cada institución determine, adecuando la asignación de actividades a las características profesionales y técnicas, así como a su nivel de responsabilidad.

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Con respecto a las actividades de capacitación y actualización, las instituciones y el personal de atención a la salud en los ámbitos privado y social que tomen, tiñan o interpreten muestras de citología cervical; realicen procedimientos colposcópicos o interpreten colposcopías y los que interpreten estudios histopatológicos de cérvix deberán apegarse a las especificaciones del “Programa Unico de Capacitación y Actualización para médicos generales, especialistas, citopatólogos y citotecnólogos”. 12.2 El grupo interinstitucional conformado a instancia del Comité Nacional de Cáncer en la Mujer, deberá desarrollar el “Programa Unico de Capacitación y Actualización para médicos generales, especialistas, citopatólogos y citotecnólogos”, conforme a las políticas, estrategias y acciones de detección, prevención y control del Cáncer Cérvico Uterino establecidas por el CNEGySR. El sector privado deberá apegarse a lo estipulado en dichas políticas. 12.3 Para la capacitación y actualización de citotecnólogos, médicos citopatólogos y médicos colposcopistas en las Instituciones de Salud públicas, se deberá aplicar el “Programa Unico de Capacitación y Actualización para médicos generales, especialistas, citopatólogos y citotecnólogos”, elaborado por el Grupo Interinstitucional. El sector privado deberá apegarse a lo estipulado en dicho Programa. 12.4 En el nivel estatal, jurisdiccional y local, en los establecimientos de salud públicos, se deben efectuar las acciones de capacitación y actualización apegadas al “Programa Unico de Capacitación y Actualización para médicos generales, especialistas, citopatólogos y citotecnólogos”, así como la adecuación para su ámbito de operación. Para el sector privado dichas acciones se delegarán en las asociaciones colegiadas de profesionistas en el área. 13. Control de calidad 13.1 Para garantizar la calidad de la prevención, detección, diagnóstico, tratamiento, control y vigilancia epidemiológica del cáncer cérvico uterino, se deben considerar todas las etapas de los procesos. 13.2 Cada citotecnólogo debe interpretar como mínimo 8400 citologías anuales en el Sector Salud, con el objeto de garantizar la correcta interpretación de los resultados. En el sector privado el citotecnólogo podrá alcanzar dicho número de citologías al sumar las que también interprete en sus otros empleos; en caso de no alcanzar el número requerido entonces se someterá a un examen de evaluación establecido por el Consejo correspondiente. 13.3 Para evaluar la calidad de un laboratorio de citología se deben considerar todas las etapas del proceso, los resultados de la evaluación deberán estar debidamente registrados en la bitácora correspondiente. 13.4 Para realizar un control de calidad adecuado, se establecen dos mecanismos: -Control Interno -Control Externo 13.5 Los procedimientos para el control de calidad interno y externo serán homogéneos en todas las instituciones del Sector Público. 13.6 El control de calidad interno debe ser aleatorio, sistemático y homogéneo; en este control se debe incluir la toma de muestras, la correlación histológica y el monitoreo del personal técnico. 13.7 Cada laboratorio deberá aplicar en forma regular el control de calidad interno, mediante el cual el patólogo o citólogo revisará todos los días el 100% de las muestras positivas, atípicas y dudosas de manera conjunta con el citotecnólogo que las leyó y una revisión aleatoria del 10% de laminillas negativas, alternativamente esta revisión de laminillas negativas puede ser realizada por un citotecnólogo con más de cinco años de experiencia. 13.8 En todos los resultados citológicos con LEIAG y cáncer se hará correlación cito-histológica 13.9 Cada laboratorio llevará un registro de productividad individual del desempeño por cada citotecnólogo, basado en una producción mínima de 40 laminillas por día, si carece de apoyo de técnico en tinción y de 56 laminillas si tiene apoyo del técnico en tinción. 13.10 El resultado del estudio citológico debe ser entregado por el laboratorio en un plazo no mayor a 10 días después de haber sido recibido.

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13.11 Respecto de las instituciones públicas, el Comité Externo de Evaluación (en el que se incluye a un grupo de expertos de diferentes entidades académicas o grupos colegiados), se encargará de la vigilancia y control de calidad externo del laboratorio. 13.12 En cada institución se realizarán visitas periódicas de supervisión a través de sus respectivos equipos de supervisores técnicos, con la periodicidad y características que cada institución determine. 13.13 El control de calidad externo para el diagnóstico citológico que se realiza en los laboratorios, incluirá la revisión de series de laminillas representativas de la patología cérvico vaginal y de los problemas técnicos. 13.14 Cada citotecnólogo, citólogo, patólogo y citopatólogo que se identifique con ineficiencia en su desempeño, deberá ser capacitado o actualizado, según corresponda, por la institución del sector salud en la que labore. 13.15 El personal que toma las muestras para el estudio citológico y que se identifique con ineficiencia en dicho procedimiento, deberá ser capacitado nuevamente. 13.16 Para brindar una atención médica de calidad, cada colposcopista deberá atender diariamente un mínimo de 15 y un máximo de 25 pacientes de las cuales, preferentemente un 30% deben ser de primera vez. 13.17 Los procedimientos colposcópicos deben ser efectuados por un médico especialista en gineco-obstetricia o en oncología quirúrgica y que cuente con diploma y cédula de la especialidad expedida por la autoridad educativa competente y que además haya llevado un curso de capacitación en colposcopía acorde a lo establecido en el “Programa Unico de Capacitación y Actualización para médicos generales, especialistas, citopatólogos y citotecnólogos” en el rubro correspondiente a colposcopía. 13.17.1 Cuando los procedimientos colposcópicos sean realizados por un médico especialista en entrenamiento en colposcopía (gineco-obstetra o cirujano oncólogo) los hará bajo la responsabilidad y supervisión de un médico especialista en la materia. 13.18 Para el control de calidad en las clínicas de colposcopía se integrará un grupo nacional e interinstitucional de expertos, conforme a las disposiciones aplicables, que cuenten con la capacitación y certificación adecuadas, para aplicar el control de calidad con criterios uniformes. 13.19 Cada clínica de colposcopía deberá llevar un registro en el que consigne la correlación citológica, colposcópica e histopatológica de las pacientes manejadas con tratamiento conservador, pretendiendo que sea del 100% cuando se trate de casos de LEIAG o cáncer in situ. 13.20 Es necesario el registro del seguimiento de todos los casos recibidos, colposcopías y biopsias realizadas y tratamientos instituidos. 13.21 La interpretación de los especímenes: conos, biopsias y piezas quirúrgicas recibidas en el laboratorio de Patología y la entrega de resultados a la paciente, deberá ser en un lapso no mayor a 15 días contados a partir de su recepción en Patología. 13.22 Se debe registrar el número de lesiones residuales y de cáncer invasor que se presenten después de tratamiento conservador. 13.23 Para evaluar la calidad de un Servicio o Centro Oncológico se deben considerar todas las etapas del proceso para la atención y seguimiento de las pacientes. Los resultados de la evaluación deberán estar debidamente registrados en la bitácora correspondiente. 14. Evaluación 14.1 Las acciones del programa se evaluarán con base en indicadores de proceso, resultado e impacto señalados en el Programa de Cáncer Cérvico Uterino vigente. 14.2 Indicador de Proceso, evalúa los siguientes aspectos: calidad de las muestras; productividad del laboratorio de citología, de patología y de las clínicas de colposcopía; oportunidad en la entrega de resultados a la usuaria (máximo 30 días) y oportunidad en el envío de la información. 14.3 Indicador de Resultado: evalúa la cobertura de detección de primera vez, la proporción de mujeres con estudios citológicos anormales (LEIBG, LEIAG y Cáncer), la proporción de estudios confirmados por histopatología y la proporción de procedimientos para tratamiento según los casos (LEIAG o Cáncer) 14.4 Indicador de Impacto: evalúa la disminución o incremento de la mortalidad por cáncer cérvico uterino en un grupo de edad determinado.

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Colposcopía

No existe lesión

Revalorar a las 12 semanas del nacimiento del producto

LEIBG, LEIAG

Invasor o tumor macroscópico

Vigilancia con citología y colposcopía cada 12 semanas

Envío a Servicio o Centro Oncológico para evaluar por el comité de ética

Revaloración a las 12 semanas del nacimiento

16. Concordancia con normas o recomendaciones internacionales y normas mexicanas Esta Norma es equivalente a la norma establecida en el Programa de Detección del Cáncer Cérvico Uterino de la Organización Mundial de la Salud 1993, así como con las recomendaciones del Manual de Normas y Procedimientos de la Organización Panamericana de la Salud, 1993. 17. Bibliografía Adam E, Berkova Z, Daxnerova Z, Icenogle J, Reeves WC, Kaufman RH. Papillomavirus detection: demographic and behavioral characteristics influencing the identification of cervical disease. Am J Obstet Gynecol 2000;182:257-264. Apgar colposcopía. Principios y práctica. Mc.Graw Hill pag. 499-503 Bergeron C. The 2001 Bethesda system. Salud Publica Mex 2003; 45 Suppl 3:S340-344. Bingham A, Bishop A, Coffey P, Winkler J, Bradley J, et al. Factors affecting utilization of cervical cancer prevention services in low-resource settings. Salud Publica Mex 2003;45 Suppl 3:S408-416. Bosch FX. Epidemiology of human papillomavirus infections: new options for cervical cancer prevention. Salud Publica Mex 2003;45 Suppl 3:S326-339. Castle PE, Wacholder S, Sherman ME, Lorincz AT, Glass AG, Scott DR, et al. Absolute risk of a subsequent abnormal pap among oncogenic human papillomavirus DNA-positive, cytologically negative women. Cancer 2002;95:2145-51. Constitución Política de los Estados Unidos Mexicanos, 15 de mayo de 2002. Crum CP. The beginning of the end for cervical cancer? N Engl J Med 2002;347:1703-1705. Cha D, Khosrotehrani K, Kim Y, Stroh H, Bianchi DW, Johnson KL. Cervical cancer and microchimerism. Obstet Gynecol 2003;102:774-781.

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Jueves 2 de febrero de 2012

DIARIO OFICIAL

(Primera Sección)

1

SECRETARIA DE SALUD PROYECTO de Modificación de la Norma Oficial Mexicana NOM-037-SSA2-2002, Para la prevención, tratamiento y control de las dislipidemias; para quedar como Proyecto de Norma Oficial Mexicana PROY-NOM037-SSA2-2010, Para la prevención, tratamiento y control de las dislipidemias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`1%&1,#@L1-1%"#/(#"%#Q(/(&%-1G)#/("#=&,H(-5,#/(#7,/1L1-%-1G)# /(# "%# 0,&$%# @L1-1%"# 7(81-%)%# 0@7:\M^:;;!_:_\\_2# =%&%# "%# W&(F()-1G)2# 5&%5%$1()5,# H# -,)5&,"# /(# "%+# /1+"1W1/($1%+R# W%&%# 3*(/%&# -,$,# =&,H(-5,# /(# 0,&$%# @L1-1%"# 7(81-%)%# =D@a:0@7:\M^:;;!_:_\V\2# =%&%# "%# W&(F()-1G)2#5&%5%$1()5,#H#-,)5&,"#/(#"%+#/1+"1W1/($1%+9# ."#W&(+()5(#W&,H(-5,#+(#W*E"1-%#()#("#`1%&1,#@L1-1%"#/(#"%#Q(/(&%-1G)#%#(L(-5,#/(#3*(#",+#1)5(&(+%/,+#/()5&,# /(#",+#+(+()5%#/<%+#)%5*&%"(+2#-,)5%/,+#%#W%&51&#/(#"%#L(-b%#/(#+*#W*E"1-%-1G)2#W&(+()5()#+*+#-,$()5%&1,+#W,&# (+-&15,# ()# 1/1,$%# (+W%c,"# H# -,)# +*+5()5,# 5J-)1-,# +*L1-1()5(# %)5(# ("# I,$15J# I,)+*"51F,# 0%-1,)%"# /(# 0,&$%"1K%-1G)# /(# =&(F()-1G)# H# I,)5&,"# /(# .)L(&$(/%/(+2# +15,# ()# ?1(d%# )P$(&,# ^2# V(&9# W1+,2# -,",)1%# e*O&(K2# `("('%-1G)# I*%*b5J$,-2# -G/1',# W,+5%"# \[[N[2# 7J81-,2# `9Q92# 5("JL,),# H# L%8# YYYM:^\Y[2# -,&&(,# ("(-5&G)1-,# W%E",9f*&1g+%"*/9',E9$89# `*&%)5(# ("# "%W+,# $()-1,)%/,# H# /(# -,)L,&$1/%/# -,)# ",# /1+W*(+5,# ()# ("# %&5<-*",# S^# L&%--1G)# B# /(# "%# ?(H# Q(/(&%"#+,E&(#7(5&,",'<%#H#0,&$%"1K%-1G)2#"%#7%)1L(+5%-1G)#/(#B$W%-5,#D('*"%5,&1,#/("#W&(+()5(#=&,H(-5,#/(# "%#),&$%#(+5%&O#%#/1+W,+1-1G)#/(#",+#1)5(&(+%/,+#()#("#/,$1-1"1,#+(c%"%/,#()#("#WO&&%L,#%)5(&1,&#H#5%$E1J)#+(# W,/&O#-,)+*"5%&#()#("#W,&5%"#("(-5&G)1-,#hhh9-,L($1&9',E9$89# PREFACIO .)#"%#("%E,&%-1G)#/(#(+5%#),&$%#W%&51-1W%&,)#"%+#*)1/%/(+#%/$1)1+5&%51F%+#(#1)+515*-1,)(+#+1'*1()5(+4# ;.ID.A!DB!#`.#;!?6`# I()5&,#0%-1,)%"#/(#=&,'&%$%+#=&(F()51F,+#H#I,)5&,"#/(#.)L(&$(/%/(+# `1&(--1G)#]()(&%"#/(#.W1/($1,",'1%# `1&(--1G)#]()(&%"#/(#I%"1/%/#H#./*-%-1G)#()#;%"*/# I()5&,#0%-1,)%"#/(#.3*1/%/#/(#]J)(&,#H#;%"*/#D(W&,/*-51F%# `1&(--1G)#]()(&%"#/(#=&,$,-1G)#/(#"%#;%"*/# `1&(--1G)#]()(&%"#/(#I,$*)1-%-1G)#;,-1%"# I,$1+1G)#I,,&/1)%/,&%#/(#B)+515*5,+#0%-1,)%"(+#/(#;%"*/#H#i,+W15%"(+#/(#!"5%#.+W(-1%"1/%/# B)+515*5,#0%-1,)%"#/(#I1()-1%+#7J/1-%+#H#0*5&1-1G)#;%"F%/,&#j*E1&O)# B)+515*5,#0%-1,)%"#/(#I%&/1,",'<%#B')%-1,#IbOF(K# i,+W15%"#]()(&%"#/(#7J81-,# ;(-&(5%&1%/,#AJ-)1-,#/("#I,)+(d,#0%-1,)%"#/(#;%"*/# ;.ID.A!DB!#`.#?!#`.Q.0;!#0!IB@0!?# `1&(--1G)#]()(&%"#/(#;%)1/%/# ;.ID.A!DB!#`.#7!DB0!# `1&(--1G)#]()(&%"#!/d*)5%#/(#;%)1/%/#0%F%"# ;.ID.A!DB!#`.#I@760BI!IB@0.;#a#AD!0;=@DA.;# `1&(--1G)#]()(&%"#/(#=&,5(--1G)#H#7(/1-1)%#=&(F()51F%#()#("#A&%)+W,&5(# B0;ABA6A@#7.TBI!0@#`.?#;.]6D@#;@IB!?# 6)1/%/#/(#;%"*/#=PE"1-%# I,,&/1)%-1G)#/(#=&,'&%$%+#B)5('&%/,+#/(#;%"*/# I,,&/1)%-1G)#/(#;%"*/#()#("#A&%E%d,## I,,&/1)%-1G)#/(#!5()-1G)#7J/1-%##

PAG. 187

2

(Primera Sección)

DIARIO OFICIAL


I,,&/1)%-1G)#/(#="%)(%-1G)#(#B)L&%(+5&*-5*&%#7J/1-%# I,,&/1)%-1G)#/(#./*-%-1G)#7J/1-%# I,,&/1)%-1G)#/(#B)F(+51'%-1G)#7J/1-%# I,,&/1)%-1G)#/(#=&(+5%-1,)(+#.-,)G$1-%+#H#;,-1%"(+## 6)1/%/#B7;;:@W,&5*)1/%/(+# B0;ABA6A@#`.#;.]6DB`!`#a#;.DUBIB@;#;@IB!?.;#`.#?@;#AD!>!e!`@D.;#`.?#.;A!`@# I,,&/1)%-1G)#/(#!+(+,&(+# ;*E/1&(--1G)#/(#=&(F()-1G)#H#=&,5(--1G)#%#"%#;%"*/# ;B;A.7!#0!IB@0!?#=!D!#.?#`.;!DD@??@#B0A.]D!?#`.#?!#Q!7B?B!# =.AD@?.@;#7.TBI!0@;# ](&()-1%#/(#;(&F1-1,+#7J/1-,+# ;.ID.A!DB!;# `.# ;!?6`# /(# ",+# (+5%/,+# /(# !'*%+-%"1()5(+2# >%d%# I%"1L,&)1%2# >%d%# I%"1L,&)1%# ;*&2# I%$W(-b(2# I,%b*1"%2# I,"1$%2# Ib1%W%+2# Ib1b*%b*%2# `1+5&15,# Q(/(&%"2# `*&%)',2# ]*%)%d*%5,2# ]*(&&(&,2# i1/%"',2#e%"1+-,2#7J81-,2#71-b,%-O)2#7,&(",+2#0%H%&152#0*(F,#?(G)2#@%8%-%2#=*(E"%2#k*(&J5%&,2#k*1)5%)%# D,,2#;%)#?*1+#=,5,+<2#;1)%",%2#;,),&%2#A%E%+-,2#A%$%*"1W%+2#A"%8-%"%2#U(&%-&*K2#a*-%5O)#H#j%-%5(-%+9# 60BU.D;B`!`#0!IB@0!?#!6A@0@7!#`.#7.TBI@# Q%-*"5%/#/(#7(/1-1)%#/(#"%#60!7# B0;ABA6A@#=@?BA.I0BI@#0!IB@0!?# .+-*("%#;*W(&1,&#/(#7(/1-1)%# @D]!0Bj!IB@0# =!0!7.DBI!0!# `.# ?!# ;!?6`2# =&,'&%$%# /(# .)L(&$(/%/(+# ),# A&%)+$1+1E"(+# H# =&,$,-1G)#/(#"%#;%"*/#@=;l7.T# Q.`.D!IB@0#7.TBI!0!#`.#`B!>.A.;2#!9I9# ;@IB.`!`#7.TBI!0!#`.#06ADBIB@0#a#.0`@IDB0@?@]B!2#!9I9# I@?.]B@#`.#7.`BIB0!#B0A.D0!#`.#7.TBI@2#!9I9# !;@IB!IB@0#0!IB@0!?#7.TBI!0!#`.#.`6I!`@D.;#.0#`B!>.A.;2#!9I9 I!7!D!#0!IB@0!?#`.#?!#B0`6;ADB!#Q!D7!I.6ABI!2# ;@IB.`!`#`.#06ADB@?@]B!2#!9I9# I@?.]B@#7.TBI!0@#`.#06ADB@?@]@;2#!9I9# Q60`!IB@0#7.TBI!0!#=!D!#?!#;!?6`2#!9I9# ;@IB.`!`#7.TBI!0!#`.#I!D`B@?@]B!# !;@IB!IB@0#0!IB@0!?#`.#I!D`B@?@]@;#`.#7.TBI@# !;@IB!IB@0# 7.TBI!0!# =!D!# ?!# =D.U.0IB@0# `.# ?!# !A.D@;I?.D@;B;# a# ;6;# I@7=?BI!IB@0.;#!9I9#m!7=!IX# !;@IB!IB@0#7.TBI!0!#`.#7.`BIB0!#B0A.]D!`!# I?B0BI!#`.#=D.U.0IB@0#`.?#DB.;]@#I@D@0!DB@#;9!9#/(#I9U9# INDICE !"#B)5&,/*--1G)# $"#@Ed(51F,#H#-%$W,#/(#%W"1-%-1G)# %"#D(L(&()-1%+# &"#`(L1)1-1,)(+# '"#;<$E,",+#H#!E&(F1%5*&%+# ("#I"%+1L1-%-1G)# )"#=&(F()-1G)#W&1$%&1%# *"#`(5(--1G)2#/1%')G+51-,#H#+('*1$1()5,# +"#A&%5%$1()5,# ,"#!+W(-5,+#/1F(&+,+#/(#"%+#/1+"1W1/($1%+# $!"#I,)-,&/%)-1%#-,)#),&$%+#1)5(&)%-1,)%"(+#H#$(81-%)%+# $$"#>1E"1,'&%L<%# $%"#@E+(&F%)-1%#/(#"%#),&$%#

PAG. 188


DIARIO OFICIAL

(Primera Sección)

3

$&"#U1'()-1%# $'"#!WJ)/1-(+# !"#-./01234456.# `*&%)5(#"%+#P"51$%+#/J-%/%+2#+(#b%#1)-&($()5%/,#"%#$,&5%"1/%/#W,&#()L(&$(/%/(+#-%&/1,F%+-*"%&(+2#b%+5%# ""('%&#%#-,)+515*1&+(#()#"%#W&1$(&%#-%*+%#/(#$,&5%"1/%/#()#",+#.+5%/,+#6)1/,+#7(81-%),+9# .)5&(#"%+#W&1)-1W%"(+#-%*+%+#W%&%#("#/(+%&&,"",#/(#(+5%+#()L(&$(/%/(+#+(#()-*()5&%#"%#%5(&,+-"(&,+1+9#?%# %5(&,+-"(&,+1+# d*('%# *)# W%W("# -()5&%"# ()# 5&(+# /(# "%+# W&1$(&%+# -1)-,# -%*+%+# /(# $*(&5(# ()# 7J81-,9# ?%# %5(&,+-"(&,+1+# (+# *)# W&,-(+,# $*"51L%-5,&1%"# -%*+%/,# W,&# L%-5,&(+# /(# &1(+',# 3*(# /%c%)# %"# ()/,5("1,# ()# L,&$%# -&G)1-%9# .)5&(# "%+# 3*(# +(# ()-*()5&%)# "%# (/%/2# b(&()-1%2# ("# 5%E%3*1+$,2# "%# F1/%# +(/()5%&1%2# "%# /1(5%# ),# +%"*/%E"(2#"%#("(F%-1G)#/(#"%#W&(+1G)#%&5(&1%"#+1+5J$1-%2#+,E&(W(+,#H#,E(+1/%/2#"%#("(F%-1G)#/(#",+#)1F("(+#/(# '"*-,+%2#%+<#-,$,#)1F("(+#/(#"?1#2:#=?@54=456.# $"$"# .+5%# 0,&$%# @L1-1%"# 7(81-%)%# 51()(# W,&# ,Ed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`1%E(5(+#()#"%#%5()-1G)#W&1$%&1%9# %"'"#0,&$%#@L1-1%"#7(81-%)%#0@7:\V^:;;!_:VNNS2#=%&%#"%#F1'1"%)-1%#(W1/($1,"G'1-%9# %"("# 0,&$%# @L1-1%"# 7(81-%)%# 0@7:\_Z:;;!_:VNNN2# =%&%# "%# W&(F()-1G)2# 5&%5%$1()5,# H# -,)5&,"# /(# "%+# %/1--1,)(+9#

PAG. 189

4

(Primera Sección)

DIARIO OFICIAL


%")"# 0,&$%# @L1-1%"# 7(81-%)%# 0@7:\M\:;;!_:_\\N2# =%&%# "%# W&(F()-1G)2#/(5(--1G)2# /1%')G+51-,2# 5&%5%$1()5,#H#-,)5&,"#/(#"%#b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`("#(8W(/1()5(#-"<)1-,9# &"#D:B5.5451.:C# =%&%#",+#L1)(+#/(#(+5%#0,&$%#+(#()51()/(#W,&4# &"$"# E4/5;52=2# FGC54=H# %# ",+# %-5,+# $,5,&(+# &(%"1K%/,+# W,&# "%+# W(&+,)%+2# -,$,# W%&5(# /(# +*+# %-51F1/%/(+# -,51/1%)%+#Hl,#W&,'&%$%/%+#m(d(&-1-1,X9# &"%"#E@5>:./=456.#4100:4/=2#%"#-,)d*)5,#/(#%"1$()5,+#)%5*&%"(+#H#W&(W%&%/,+#3*(#+(#-,)+*$()#-%/%#/<%# -,)# (3*1"1E&1,2# F%&1(/%/# H# +*L1-1()-1%# ()# -%",&<%+2# W&,5(<)%+2# -%&E,b1/&%5,+2# '&%+%+2# F15%$1)%+2# L1E&%# H# $1-&,)*5&1()5(+2#%+<#-,$,#"%#1)'(+5%#/(#%'*%2#W%&%#5()(&#*)%#)*5&1-1G)#-,&W,&%"#%/(-*%/%#3*(#+(#5&%/*K-%#()# (+5%/,#)*5&1-1,)%"#%/(-*%/,#W%&%#"%#(/%/#H#+(8,9# &"&"#E/:01C4@:01C5C2#(+#*)%#()L(&$(/%/#3*(#%L(-5%#1)1-1%"$()5(#%#"%#<)51$%#/(#"%+#%&5(&1%+#/(#/1+5&1E*-1G)2# -,)#/%c,#()/,5("1%"#(#1)L"%$%-1G)2#3*(#+(#-%&%-5(&1K%#W,&#/(WG+15,#/(#"5=# :.# /0=/=>5:./12# %"# -,)d*)5,# /(# W(&+,)%+# -,)# /1%')G+51-,# -,),-1/,# /(# /1+"1W1/($1%+# 3*(# -*&+%)# -,)# )1F("(+# /(# 5&1'"1-J&1/,+2# -,"(+5(&,"# 5,5%"2# I:i`?2# I:),# i`?#,#I:?`?#-,)5&,"%/,+#()#&(+W*(+5%#%"#5&%5%$1()5,#,#-,)51)P%)#+1)#-,)5&,"#%#W(+%&#/("#5&%5%$1()5,9# &")"#I=C1C#:.#41./01@2#W%-1()5(#-,)#%"'P)#51W,#/(#/1+"1W1/($1%#E%d,#5&%5%$1()5,#()#("#;1+5($%#0%-1,)%"#/(# ;%"*/#H#3*(#W&(+()5%)#)1F("(+#/(#-,"(+5(&,"#5,5%"#o#_\\#$'l/?2#5&1'"1-J&1/,+#o#VY\#$'l/?#H#I:i`?##S\#$'l/?9# &"*"# I=C1# .3:;1# 2:# 25C@5?52:>5=2# W%-1()5(# 3*(# -*$W"(# -,)# ",+# -&15(&1,+# /(# /1%')G+51-,+# ()*)-1%/,+# ()# (+5%#),&$%#H#3*(#(+#&('1+5&%/,#W,&#W&1$(&%#F(K#W,&#("#;1+5($%#0%-1,)%"#/(#B)L,&$%-1G)#()#;%"*/9# &"+"#I=C1#?018=8@:#2:#25C@5?52:>5=2#%#"%#W(&+,)%#3*(#()#*)%#5,$%#,-%+1,)%"#W%&%#+*#/(5(--1G)2#,E5()'%# *)#)1F("#/(#-,"(+5(&,"#5,5%"##_\\#$'l/?#,#A&1'"1-J&1/,+##VY\#$'l/?#,#I:i`?#o#S\#$'l/?#,#I,"(+5(&,"#),#i`?# #V[\#$'l/?9# &","# I1@:C/:01@2# %# "%# $,"J-*"%# (+5(&,1/(%2# L,&$%/%# W,&# -*%5&,# %)1"",+# b1/&,-%&E,)%/,+# $O+# *)%# -%/()%# %"1LO51-%#/(#,-b,#O5,$,+#/(#-%&E,),#()#("#I:V^#H#*)#@i#()#("#I:M#/("#%)1"",#!9#!*)3*(#/(+/(#("#W*)5,#/(#F1+5%# 3*<$1-,#(+#*)#%"-,b,"2#W,+((#W&,W1(/%/(+#L<+1-%+#+($(d%)5(+#%#"%+#/(#*)#"2# /(E1/,#%#3*(#51()()#*)#%"5,#-,)5()1/,#W&,5(1-,9#=,&#("",#+,)#-,),-1/%+#-,$,#"1W,W&,5(<)%+#/(#%"5%#/()+1/%/9# &"$$"#I1@:C/:01@#LDL#mW,&#+*+#+1'"%+#()#1)'"J+2#IMLDLH#L1O#D:.C5/<#L5?1?01/:5.X2#(+#"%#-,)-()5&%-1G)#/(# -,"(+5(&,"#-,)5()1/,#()#"%+#"1W,W&,5(<)%+#/(#E%d%#/()+1/%/2#5&%)+W,&5%)#("#-,"(+5(&,"#%#",+#5(d1/,+2#+*#("(F%-1G)# L%F,&(-()#"%#%W%&1-1G)#/(#%5(&,(+-"(&,+1+#H#W,&#",#5%)5,#/(#W&,E"($%+#-%&/1,F%+-*"%&(+9# &"$%"# I1@:C/:01@# .1# KDLH# (+# 5,/,# ("# -,"(+5(&,"# 3*(# ),# (+# 5&%+W,&5%/,# W,&# ("# I,"(+5(&,"# i`?# H# (+# W,5()-1%"$()5(#%5(&,'J)1-,9#;(#+*'1(&(#("#*+,#/("#-,"(+5(&,"#),:i`?#mI:),:i`?X#-,$,#*)%#b(&&%$1()5%#W%&%# (F%"*%&#("#&1(+',#/(#$*(&5(#W,&#()L(&$(/%/#-%&/1,F%+-*"%&9#."#I:),:i`?#+(#/(L1)(#-,$,#"%#/1L(&()-1%#()5&(#("# F%",&#/(#-,"(+5(&,"#5,5%"#H#("#-,"(+5(&,"#/(#"%+#i`?#mI:),:i`?p#IA#:#I:i`?X2#H#-,$W&()/(#"%+#L&%--1,)(+#/(# "1W,W&,5(<)%+4#?`?2#B`?2#H#U?`?2#(#1)-"*H(#W%&5<-*"%+#%"5%$()5(#%5(&,'J)1-%+#-,$,#",+#&($%)()5(+#/(#U?`?#H# ?W#m%X# &"$&"#D:/:4456.2#%#"%#EP+3*(/%#%-51F%#/(#W(&+,)%+#-,)#/1+"1W1/($1%#),#/1%'),+51-%/%9# &"$'"#D5=8:/:C#>:@@5/3C2#%#"%#()L(&$(/%/#+1+5J$1-%2#-&G)1-,:/('()(&%51F%2#/(#-%&O-5(&# b(5(&,'J)(,2#-,)# '&%/,+#F%&1%E"(+#/(#W&(/1+W,+1-1G)#b(&(/15%&1%#H#-,)#W%&51-1W%-1G)#/(#/1F(&+,+#L%-5,&(+#%$E1()5%"(+2#H#3*(#+(#

PAG. 190


DIARIO OFICIAL

(Primera Sección)

5

-%&%-5(&1K%#W,&#b1W(&'"*-($1%#-&G)1-%#/(E1/,#%#"%#/(L1-1()-1%#()#"%#W&,/*--1G)#,#%--1G)#/(#"%#1)+*"1)%2#",#3*(# %L(-5%#%"#$(5%E,"1+$,#1)5(&$(/1,#/(#",+#b1/&%5,+#/(#-%&E,),2#W&,5(<)%+#H#'&%+%+9# &"$("#D5:/=2#%"#-,)d*)5,#/(#%"1$()5,+#3*(#+(#-,)+*$()#-%/%#/<%9# &"$)"#D5C@5?52:>5=C2#%#"%#%"5(&%-1G)#/(#"%#-,)-()5&%-1G)#),&$%"#/(#",+#":2=2# 4=0251;=C43@=0# ?0:>=/30=H# %# "%# %W%&1-1G)# /(# $%)1L(+5%-1,)(+# /(# ()L(&$(/%/# -%&/1,F%+-*"%&#()#b,$E&(+#$(),&(+#/(#YY#%c,+#,#$*d(&(+#$(),&(+#/(#[Y#%c,+9# &"$,"# PC/5@1C# 2:# ;52=# C=@32=8@:H# +(# &(L1(&(# %# -,$W,&5%$1()5,+# 3*(# /1+$1)*H()# ",+# &1(',+# /(# ()L(&$%&2# 5%"(+# -,$,4# %"1$()5%-1G)# -,&&(-5%2# %/(-*%/,# -,)5&,"# H# 5&%5%$1()5,# /(# "%+# 5()+1,)(+# H# ($,-1,)(+# )('%51F%+R# E*()# &J'1$()# /(# (d(&-1-1,+2# +*(c,# H# /1+5&%--1G)R# ("# -,)5&,"# H# "%# (F15%-1G)# /("# %E*+,# /(# +*+5%)-1%+# -,$,# "%# -%L(<)%2#)1-,51)%#H#%"-,b,"R#*)%#-,&&(-5%#/1+5&1E*-1G)#H#%W&,F(-b%$1()5,#/("#51($W,9# &"%!"# PR?:25:./:# [email protected]# %"# -,)d*)5,# /(# 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PAG. 191

6

(Primera Sección)

DIARIO OFICIAL


&"&("#A=456.#1#?10456.2#%#"%#-%)51/%/#/(#%"1$()5,+#(8W&(+%/%#()#$(/1/%+#/(#*+,#-,$P)#W%&%#-%/%#'&*W,# /(#%"1$()5,+#3*(#+(#*51"1K%#W%&%#"%#W&(+-&1W-1G)#/1(5J51-%9# &"&)"#A:C5C/:.45=#=#@=#5.C3@5.=2#%#"%#/1+$1)*-1G)#/(#"%#%--1G)#/(#(+5%# b,&$,)%#()#",+#5(d1/,+#$*+-*"%&2# b(WO51-,#H#%/1W,+,9# &"&*"#Q:J3.21#.5;:@#2:#=/:.456.2#%#"%+#*)1/%/(+#3*(#%51()/()#",+#W&,E"($%+#/(#+%"*/#3*(#%#-%*+%#/(#+*# -,$W"(d1/%/#),#W*(/()#+(&#&(+*("5,+#()#("#W&1$(&#)1F("#/(#%5()-1G)9# &"&+"# QG.201>:# >:/=86@541H# %"# -,)d*)5,# /(# %),&$%"1/%/(+# E1,3*<$1-%+2# L1+1,"G'1-%+# H# %)5&,W,$J5&1-%+2# 3*(#,-*&&()#+1$*"5O)(%$()5(#H#W*(/()#W&,/*-1&#,#(+5%&#"1'%/%+#%#"%#&(+1+5()-1%#%#"%#1)+*"1)%#Hl,#+,E&(W(+,#*# ,E(+1/%/# -()5&%"2# 3*(# 1)-&($()5%)# ("# &1(+',# /(# /(+%&&,""%&# `1%E(5(+# $(""15*+2# ()L(&$(/%/# -%&/1,F%+-*"%&# ,# %$E%+9# ;*+# -,$W,)()5(+# L*)/%$()5%"(+# +,)4# ,E(+1/%/# %E/,$1)%"2# W&(`1%E(5(+# ,# `1%E(5(+# $(""15*+# 51W,# _2# b1W(&5()+1G)#%&5(&1%"#,#W&(+1G)#%&5(&1%"#L&,)5(&1K%2#/1+"1W1/($1%#mb1W(5&1'"1-(&1/($1%#Hl,#i`?#E%d,X9# &"&,"#X=8=Y35C>1H#(+#"%#%/1--1G)#%"#5%E%-,#*#,5&,+#W&,/*-5,+#/("#5%E%-,9# &"&,"$"# =%&%# (L(-5,+# /(# ",# /1+W*(+5,# ()# (+5%# ),&$%2# +(# -,)+1/(&%&O# -,$,# L*$%/,&# %# 5,/%# W(&+,)%# 3*(# b*E1(+(#L*$%/,#W,&#",#$(),+#*)#-1'%&&1"",# ,#-,)+*$1/,#,5&,+#W&,/*-5,+# /("#5%E%-,2#()#("#P"51$,#$(+#,#(+5J# (8W*(+5%#()#L,&$%#+,+5()1/%#%"#b*$,#/("#5%E%-,9# &"'!"# X05J@54S0521C2# %# "%+# $,"J-*"%+# /(# '"1-(&,"2# (+5(&1L1-%/%+# -,)# 5&(+# O-1/,+# '&%+,+9# =&1)-1W%"# L,&$%# /(# %"$%-()%$1()5,#/(#()(&'<%#()#("#,&'%)1+$,9#A%$E1J)#""%$%/,+#5&1%-1"'"1-(&,"(+9# &"'$"# Z=./1>=C# :03?/5;1C2# %# ",+# /(WG+15,+# "1W=C# /:.25.1C1C2# %# ",+# /(WG+15,+# "1W=C# /38:01C1C2# %# ",+# /(WG+15,+# "1W81@1C#<#E80:;5=/30=C# EW7#[# !W,"1W,W&,5(<)%#># EW7#I--## !W,"1W,W&,5(<)%#IBB# I-P#$!# I"%+1L1-%-1G)#B)5(&)%-1,)%"#/(#.)L(&$(/%/(+#`J-1$%#./1-1G)# IMKDL# I,"(+5(&,"#/(#"1W,W&,5(<)%+#/(#%"5%#/()+1/%/# IMLDL# I,"(+5(&,"#/(#"1W,W&,5(<)%+#/(#E%d%#/()+1/%/# IM.1MKDL# I,"(+5(&,"#),#i`?# IX# I,"(+5(&,"#5,5%"# P\QE\]X# .)-*(+5%#0%-1,)%"#/(#;%"*/#H#0*5&1-1G)# J# ]&%$,+# KEQ# i1W(&5()+1G)#!&5(&1%"#;1+5J$1-%# KU^MI1E# i1/&,81$(51":'"*5%&1":-,()K1$%#!# -DL# ?1W,W&,5(<)%#/(#/()+1/%/#1)5(&$(/1%# -UI# B)/1-(#/(#7%+%#I,&W,&%"# KI# i1/&%5,+#/(#I%&E,),# _4=@# C1",-%",&<%# _J`>%# C1",'&%$,+#W,&#$(5&,#/(#(+5%5*&%#%"#-*%/&%/,# LDL## ?1W,W&,5(<)%+#/(#E%d%#/()+1/%/# L?## ?1W,W&,5(<)%+# >J# 71"1'&%$,# >J`2G=## 71"1'&%$,+#W,&#/<%# >J`2L# 71"1'&%$,+#W,&#/(-1"15&,# >@`2G=# 71"1"15&,+#W,&#/<%# \IPW# 0%51,)%"#Ib,"(+5(&,"#./*-%51,)#=&,'&%$# \7U# 0,&$%#@L1-1%"#7(81-%)%# W7E# =&,/*-5,#/(#@&1'()#!)1$%"# X^# A&1'"1-J&1/,+# XQK## i,&$,)%#(+51$*"%)5(#/(#"%#51&,1/(+#mW,&#+*+#+1'"%+#()#B)'"J+#AbH&,1/#;51$*"%51)'i,&$,)(X# aLDL## ?1W,W&,5(<)%+#/(#$*H#E%d%#/()+1/%/#

PAG. 192


DIARIO OFICIAL

(Primera Sección)

7

aPX# U%",&#.)(&'J51-,#A,5%"# b# =,&-()5%d(# c# 7%H,*(# d# 7(),*(# c# 7%H,'*%"#3*(# d# 7(),'*%"#3*(# ("#I@=C5B54=456.# ("$"#?,+#)1F("(+#/(#"9# ("$"&"# IO"-*",# /(# "%# (/%/# F%+-*"%&2# (+# *)# -,)-(W5,# 3*(# (8W&(+%# /(# $%)(&%# $O+# -,$W&()+1E"(# W%&%# W%-1()5(+#H#W%&%#("#W(&+,)%"#$J/1-,2#("#'&%/,#/(#&1(+',#W%&%#/(+%&&,""%&#()L(&$(/%/#-%&/1,F%+-*"%&9# ("$"&"$"#=%&%#("#-O"-*",#/(#(/%/#F%+-*"%&#&(L(&1&+(#%"#!WJ)/1-(#I9# ("%"#I"%+1L1-%-1G)#/1%')G+51-%#/(#"%+#/1+"1W1/($1%+#-,$,#()L(&$(/%/2#+(#&(F1+%#()#("#!WJ)/1-(#`9# ("&"# IG/1',# /(# D('1+5&,# /(# "%+# `1+"1W1/($1%+# ()# "%# I"%+1L1-%-1G)# B)5(&)%-1,)%"# /(# .)L(&$(/%/(+# mIB.X2# /J-1$%#&(F1+1G)#()#("#!WJ)/1-(#.9# )"#W0:;:.456.#?05>=05=# )"$"# ?%+# /1+"1W1/($1%+# /(E()# W&(F()1&+(# $(/1%)5(# "%# &(-,$()/%-1G)# /(# *)%# %"1$()5%-1G)# -,&&(-5%# H# %-51F1/%/#L<+1-%#%/(-*%/%9#!#(8-(W-1G)#/(#"%+#/(#,&1'()#'()J51-,#,#W&1$%&1%+9# )"%"# ?%+# %--1,)(+# /(# W&(F()-1G)# W%&%# &(/*-1&# ("# &1(+',# /(# ()L(&$(/%/# -%&/1,F%+-*"%&# /(E()# 5()(&# -,$,# ,Ed(51F,#&(/*-1&#"%#1)'(+5%#/(#'&%+%+#+%5*&%/%+#H#/(#-,"(+5(&,"#/(+/(#"%#)1c(K2#/(&1F%/%+#/(#-1)-,#(+5&%5('1%+4# VX#!"1$()5%-1G)#-,&&(-5%2#_X#7%)5()1$1()5,#/("#W(&L1"#"1W9# )"&"# ."# -,)5&,"# 1)5('&%"2# 5($W&%),# H# +,+5()1/,# /(# ",+# /1F(&+,+# L%-5,&(+# /(# &1(+',# -%&/1,F%+-*"%&2# (+# "%# W&1)-1W%"# b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c%"%/,# ()# "%+# ),&$%+# W%&%# "%# =&(F()-1G)2# A&%5%$1()5,# H# I,)5&,"# /(# "%# `1%E(5(+2#/(#"%#i1W(&5()+1G)#!&5(&1%"#;1+5J$1-%2#/("#IO)-(&#-J&F1-,#*5(&1),#H#IO)-(&#/(#$%$%2#-15%/%+#()#",+# W*)5,+#_9V#%"#_9N#/("#%W%&5%/,#/(#&(L(&()-1%+#/(#"%#W&(+()5(#),&$%9# )"*"%"# ?%+# %--1,)(+# /(# W&,$,-1G)# /(# "%# +%"*/# H# /(# W&(F()-1G)# /(# "%+# /1+"1W1/($1%+# +(# ,&1()5%)# W&1)-1W%"$()5(#%"#L,$()5,#/(#(+51",+#/(#F1/%#+%"*/%E"(+2#%/($O+#/(#1)5('&%&+(#%#"%+#(+5&%5('1%+#H#W&,'&%$%+# W%&%# "%# W&(F()-1G)# /(# "%+# ()L(&$(/%/(+# /("# -,&%KG)2# -(&(E&,F%+-*"%&(+2# ,E(+1/%/2# /1%E(5(+2# b1W(&5()+1G)# %&5(&1%"#H#,5&,+#W%/(-1$1()5,+#-&G)1-,+9#

PAG. 193

8

(Primera Sección)

DIARIO OFICIAL


)"*"&"#."#%W,&5(#-%"G&1-,#/(#"%#/1(5%2#()#*)%#W(&+,)%#()#W(+,#%/(-*%/,#*)%#1)'(+5%#()5&(#_\#%#_Y#C-%"lC'2# +1# +*# W(+,# (+5O# W,&# %&&1E%# /(# ",# &(-,$()/%/,2# ("# %W,&5(# +(&O# ()5&(# VY# %# _\# C-%"lC'# /(# W(+,9# =%&%# $O+# 1)L,&$%-1G)#F(&#("#!WJ)/1-(#Q9# )"*"'"# ."# -,)5()1/,# /(# '&%+%# /(# "%# /1(5%# -,&&(+W,)/(# %"# _Y:M\n# /(# "%+# -%",&<%+# 5,5%"(+# 1)'(&1/%+2# /(# "%+# -*%"(+#o#V\n#-,&&(+W,)/(&O#%#"%+#'&%+%+#+%5*&%/%+2#V\n#'&%+%+#$,),:1)+%5*&%/%+#H#V\n#W,"1:1)+%5*&%/%+R#+1# -,)#(+5%+#1)/1-%-1,)(+#+(#-,)51)P%#-,)#)1F("(+#%"5,+#/(#-,"(+5(&,"2#"%+#-%)51/%/(+#/(#'&%+%+#+%5*&%/%+2#/(E(# &(/*-1&+(#%"#^n#/("#-,)5()1/,#-%"G&1-,#5,5%"#/(#"%#/1(5%9#;(#%-,)+(d%#-,)+*$1&#$(),+#/(#_\\#$'#/(#-,"(+5(&,"# W,&#/<%9#=%&%#$O+#1)L,&$%-1G)#F(&#("#!WJ)/1-(#Q9# )"*"("#=%&%#("#-O"-*",#/(#-%",&<%+#H#"%#-,$W,+1-1G)#)*5&1$()5%"#/(#b1/&%5,+#/(#-%&E,),2#W&,5(<)%+#H#"
PAG. 194


DIARIO OFICIAL

(Primera Sección)

9

)"$'"#=%&51-1W%-1G)#;,-1%"9# )"$'"$"# ."# ;1+5($%# 0%-1,)%"# /(# ;%"*/# /(E(# 1$W*"+%&# "%# W%&51-1W%-1G)# /(# "%+# %*5,&1/%/(+# $*)1-1W%"(+# H# -,$*)15%&1%+2# %+<#-,$,#/(#'&*W,+# H# ,&'%)1K%-1,)(+#+,-1%"(+#W%&%#W&,$,F(&#"%#%/,W-1G)#/(#(+51",+#/(#F1/%# H# -,)/*-5%+#+%"*/%E"(+2#W%&51-*"%&$()5(#()5&(#",+#'&*W,+#/(#$%H,&#&1(+',9# )"$'"%"# ."# ;1+5($%# 0%-1,)%"# /(# ;%"*/2# $(/1%)5(# "%# -,"%E,&%-1G)# -,)# ,&'%)1K%-1,)(+# WPE"1-%+# H# W&1F%/%+2# ()# W%&51-*"%&# -,)# "%# 1)/*+5&1%# %"1$()5%&1%# H# ,&'%)1K%-1,)(+# /(# (+5%E"(-1$1()5,+# /(/1-%/,+# %# "%# F()5%# /(# %"1$()5,+2# ("# ;(-5,&# ;%"*/# (+5%E"(-(&O# %--1,)(+# W(&$%)()5(+# W%&%# 3*(# +(# ,L&(K-%)# %"# WPE"1-,# %"1$()5,+# +%"*/%E"(+#3*(#-,)5&1E*H%)#%#"%#W&(F()-1G)#H#%"#-,)5&,"#/(#"%+#/1+"1W1/($1%+9# )"$'"&"#7(/1%)5(#"%#-,,&/1)%-1G)#/(#%--1,)(+#-,)#"%+#1)+515*-1,)(+#H#/(W()/()-1%+#WPE"1-%+#H#W&1F%/%+2#%+<# -,$,#-,)#"%+#%+,-1%-1,)(+#/(#W&,L(+1,)%"(+#&("%-1,)%/,+#-,)#"%+#%-51F1/%/(+#L<+1-%+2#("#/(W,&5(#H#"%#(/*-%-1G)# L<+1-%2#("#;(-5,&#;%"*/#/(E(#W&,$,F(&#(+5%+#%-51F1/%/(+#()5&(#"%#W,E"%-1G)#()#'()(&%"9# )"$'"'"# ."# ;(-5,&# ;%"*/# /(E(# L,&5%"(-(&# "%# -,,&/1)%-1G)# -,)# %+,-1%-1,)(+# /(# W&,L(+1,)%"(+# /(# "%# -,$*)1-%-1G)# W%&%# W"%)(%&# H# (d(-*5%&# -%$W%c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l,#W&(F()1/,+9# )"$("%"# ."# ;1+5($%# 0%-1,)%"# /(# ;%"*/# /(E(# (L(-5*%&# -%$W%c%+# W%&%# (/*-%&# %# "%# W,E"%-1G)# +,E&(# "%# W&(F()-1G)#/(#"%+#/1+"1W1/($1%+9# )"$("&"# ."# ;1+5($%# 0%-1,)%"# /(# ;%"*/# /(E(# W&,$,F(&# (+5&%5('1%+# 3*(# W&,W1-1()# %-515*/(+# 5()/1()5(+# %# $(d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l,# /(# %"-,b,"2# 1)+*L1-1()5(# 1)'(+5%# /(# W,5%+1,2# b1W(&*&1-($1%2# W&(+1G)# %&5(&1%"# L&,)5(&1K%2# b1W(&5()+1G)# %&5(&1%"# +1+5J$1-%2# %)5(-(/()5(+#L%$1"1%&(+#/(#b1W(&5()+1G)#%&5(&1%"#+1+5J$1-%2#%)5(-(/()5(+#L%$1"1%&(+#/(#/1+"1W1/($1%+2#/%5,+#/(# &(+1+5()-1%# %# "%# 1)+*"1)%2# /1%E(5(+2# +<)/&,$(# $(5%EG"1-,# H# /(# ",+# [Y# %c,+# /(# (/%/# ()# %/("%)5(2# 1)5('&%)# ("# '&*W,#()#$%H,&#&1(+',#/(#""('%&#%#/(+%&&,""%&#/1+"1W1/($1%+9# )"$)"%"# ?%+# W(&+,)%+# ()# +15*%-1G)# /(# %"5,# &1(+',# -%&/1,F%+-*"%&# /(E()# +(&# 1)L,&$%/%+# H# %W,H%/%+# W%&%# (L(-5*%&#",+#-%$E1,+# )(-(+%&1,+#()#+*+#(+51",+#/(#F1/%#H#&(-1E1)L,&$%-1G)#+,E&(# "%# W&,E%E"(#)(-(+1/%/# /(# 5,$%&#$(/1-%$()5,+#W,&#("#&(+5,#/(#+*#F1/%9# )"$)"&"#?%# W&(F()-1G)#(+W(-5:./1# *"$"#`(5(--1G)9# *"$"$"# .)# W(&+,)%+# $%H,&(+# /(# _\# %c,+# /(# (/%/2# +(# W*(/(# &(%"1K%&# *)%# W&*(E%# /(# /(5(--1G)# &OW1/%# m3*<$1-%#+(-%X#%*)3*(#(+#)(-(+%&1%#"%#$(/1-1G)#/("#W(&L1"#/(#"
PAG. 195

10

(Primera Sección)

DIARIO OFICIAL


*"$"%"#.)#W(&+,)%+#-,)#L%-5,&(+#/(#&1(+',#,#%)5(-(/()5(+#L%$1"1%&(+#/(#5&%+5,&),+#/(#",+#"
PAG. 196


DIARIO OFICIAL

(Primera Sección)

11

*"&"%"#.)#W%-1()5(+#-,)#",+#)1F("(+#/(#"5:./1# +"$"# ."# (+3*($%# '()(&%"# W%&%# ("# 5&%5%$1()5,# )*5&1-1,# H# L%&$%-,"G'1-,# /(# W%-1()5(+# -,)# /1+"1W1/($1%+2# +(# E%+%#()#("#F%",&#/(#"#H#"%+#&(-,$()/%-1,)(+#()#",+#!WJ)/1-(+#Q#H#]9# +"%"# =%&%# ("# 5&%5%$1()5,# (+W(-
PAG. 197

12

(Primera Sección)

DIARIO OFICIAL


r]*<%# /(# 5&%5%$1()5,# L%&$%-,"G'1-,# /(# /1+"1W1/($1%+s# /1+W,)1E"(# ()# "%# WO'1)%# ("(-5&G)1-%4# hhh9-()%F(-(9+%"*/9',E9$8# +"("&"# .)# ("# -%+,# /(# 3*(# ),# +(# ",'&()# "%+# $(5%+# /("# 5&%5%$1()5,# -,)# ("# LO&$%-,# 1)1-1%"2# +(# ($W"(%# ,5&,# LO&$%-,2# ,# *)%# -,$E1)%-1G)# /(# /,+# /(# ("",+2# %*)3*(# ()# "%# $%H,&<%# /(# ",+# -%+,+# ("# *+,# -*1/%/,+,# /(# *)# LO&$%-,#&(+*"5%#+*L1-1()5(9# ,"#EC?:4/1C#25;:0C1C#2:#@=C#25C@5?52:>5=C# ,"$"#i1W(&5()+1G)#%&5(&1%"#%+,-1%/%#%#/1+"1W1/($1%9# ,"$"$#=%-1()5(+#-,)#b1W(&5()+1G)#%&5(&1%"#+1+5J$1-%#H#,5&,+#L%-5,&(+#/(#&1(+',#%+,-1%/,+2#,E51()()#E()(L1-1,# +*+5%)-1%"#/("#5&%5%$1()5,#-,)#(+5%51)%2#%*)3*(#+*+#)1F("(+#E%+%"(+#/(#I:?`?#+(%)#o#VM\#$'l/?9# ,"%"#.)L(&$(/%/#&()%"#%+,-1%/%#%#/1+"1W1/($1%9# ,"%"$"# =%-1()5(+# -,)# 1)+*L1-1()-1%# &()%"# -&G)1-%2# ,E51()()# E()(L1-1,# -,)# ("# *+,# /(# (+5%51)%+2# +1)# ($E%&',# 51()()# *)# $%H,&# &1(+',# /(# /(+%&&,""%&# $1,W%5<%# W,&# b1W,"1W($1%)5(+2# W,&# ",# -*%"# /(E()# /(# F1'1"%&+(# (+5&(-b%$()5(9# ,"&"#`1%E(5(+#%+,-1%/%#%#/1+"1W1/($1%9# ,"&"$"# .)# W%-1()5(+# -,)# `1%E(5(+# $(""15*+2# "%# $(/1/%# 5(&%WJ*51-%# 3*(# /1+$1)*H(# ()# $%H,&# $%')15*/# ("# &1(+',# -%&/1,F%+-*"%&# (+# ("# 5&%5%$1()5,# b1W,"1W($1%)5(# E%+%/,# ()# (+5%51)%+9# ;1)# ($E%&',2# /%/,# 3*(# $*-b,+# /(#(+5,+#W%-1()5(+#),#%"-%)K%)#("#-,)5&,"#1)5('&%"#/(#+*#W(&L1"#/(#"=C#5./:0.=451.=@:C#<#>:R54=.=C# $!"$"#.+5%#0,&$%#(+#W%&-1%"$()5(#(3*1F%"()5(#%#"%+#+1'*1()5(+#),&$%+#1)5(&)%-1,)%"(+4# $!"$"$"# .8W(&5# =%)("# ,)# `(5(-51,)2# .F%"*%51,)2# %)/# A&(%5$()5# ,L# i1'b# >",,/# Ib,"(+5(&,"# 1)# !/*"5+9# ;*$$%&H#,L#5b(#5b1&/#D(W,&5#,L#5b(#0%51,)%"#Ib,"(+5(&,"#./*-%51,)#=&,'&%$#m0I.=X9# $!"$"%"#iHW(&5()+1,)#I,)5&,"4#D(W,&5#,L#%#ti@# $!"$"'"#@7;#=&(F()-1G)#H#"*-b%#-,)5&%#"%+#()L(&$(/%/(+#-%&/1,F%+-*"%&(+#()#"%#-,$*)1/%/9#B)L,&$(#/(# *)#I,$15J#/(#.8W(&5,+#/(#"%#@7;9#;(&1(#/(#B)L,&$(+#AJ-)1-,+#^M_9#@7;2#]1)(E&%2#VNZ[9# $!"$"("#ti@9#=&(F()51,)#,L#`1%E(5(+#7(""15*+9#ti@#A(-b)1-%"#D(W,&5#;(&1(+9#]()(F%#VNNS9# $!"%"#?%#W&(+()5(#0,&$%#),#(+#(3*1F%"()5(#%#)1)'*)%#,5&%#),&$%#$(81-%)%9# $$"#[58@51J0=BG=# $$"$"# !'*1"%&:;%"1)%+# I!2# 7(b5%# D2# D,d%+# D2# ]G$(K:=J&(K# Qe2# @"%1K# ]2# D*""# e!9# 7%)%'($()5# ,L# 5b(# $(5%E,"1-# +H)/&,$(# %+# %# +5&%5('H# L,&# W&(F()51)'# 5b(# $%-&,F%+-*"%&# -,$W"1-%51,)+# ,L# 5HW(# _# `1%E(5(+4# -,)5&,F(&+1%"#1++*(+9#I*&&()5#`1%E(5(+#D(F1(h+#_\\Y4V4#VSY:VYZ9# $$"%"#!'*1"%&#;%"1)%+#I!2#]G$(K#=J&(K#Qe2#?(&$%)#B2#=J&(K#@2#=,+%/%+#I9#`1%')G+51-,#H#5&%5%$1()5,#/(# "%+#`1+"1W1/($1%+R#=,+5*&%#/(#"%#;,-1(/%/#7(81-%)%#/(#0*5&1-1G)#H#.)/,-&1),",'<%9#D(F1+5%#/(#.)/,-&1),",'<%# H#0*5&1-1G)9#_\\SR#V_4#^:SV# $$"&"# !"-,-(&# ?2# =%&&%# ej2# i(&)O)/(K# ii9# U(&+1G)# $1)1$%"1+5%# /("# 5&%5%$1()5,# %)51b1W(&5()+,&9# D(F# 7(8# I%&/1,"#_\\ZR#VN#mVX4M:[9#

PAG. 198


DIARIO OFICIAL

(Primera Sección)

15

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PAG. 199

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(Primera Sección)

DIARIO OFICIAL


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PAG. 201

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PAG. 205

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PAG. 206


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PAG. 207

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PAG. 208


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(Primera Sección)

25

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PAG. 209

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DIARIO OFICIAL


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12066$

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12066$

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12066$

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12066$

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12066$

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12066$

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