Compartir
array:23 [ "pii" => "S0210570523004752" "issn" => "02105705" "doi" => "10.1016/j.gastrohep.2023.11.005" "estado" => "S300" "fechaPublicacion" => "2024-04-01" "aid" => "2142" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2023" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Gastroenterol Hepatol. 2024;47:391-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S0210570524000530" "issn" => "02105705" "doi" => "10.1016/j.gastrohep.2024.02.004" "estado" => "S300" "fechaPublicacion" => "2024-04-01" "aid" => "2173" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Gastroenterol Hepatol. 2024;47:393-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Young corner</span>" "titulo" => "MASLD biomarkers: Are we facing a new era?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "393" "paginaFinal" => "396" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Biomarcadores en MASLD, ¿estamos ante una nueva era?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2439 "Ancho" => 2925 "Tamanyo" => 500218 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Facing a new era in MASLD biomarkers. Progressive forms of liver disease require the use of targeted therapies adapted to stratified groups of patients, considering the main drivers of the disease to define patients’ subphenotypes. Biomarkers have proven diagnostic accuracy in targeted populations (higher prevalence), but require further validation in primary care settings (lower prevalence) for screening purposes.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Douglas Maya-Miles, Javier Ampuero, David Martí-Aguado, Andrés Conthe, Rocío Gallego-Durán" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Douglas" "apellidos" => "Maya-Miles" ] 1 => array:2 [ "nombre" => "Javier" "apellidos" => "Ampuero" ] 2 => array:2 [ "nombre" => "David" "apellidos" => "Martí-Aguado" ] 3 => array:2 [ "nombre" => "Andrés" "apellidos" => "Conthe" ] 4 => array:2 [ "nombre" => "Rocío" "apellidos" => "Gallego-Durán" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570524000530?idApp=UINPBA00004N" "url" => "/02105705/0000004700000004/v2_202406091228/S0210570524000530/v2_202406091228/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0210570523003254" "issn" => "02105705" "doi" => "10.1016/j.gastrohep.2023.04.005" "estado" => "S300" "fechaPublicacion" => "2024-04-01" "aid" => "2075" "copyright" => "The Authors" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Gastroenterol Hepatol. 2024;47:389-90" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Imagen del mes</span>" "titulo" => "Quiste de duplicación entérica como presentación poco frecuente de abdomen agudo en adulto" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "389" "paginaFinal" => "390" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Enteric duplication cyst as a rare presentation of adult acute abdomen" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 572 "Ancho" => 1340 "Tamanyo" => 99532 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Imagen A: ecografía abdominal que muestra una lesión bien definida y anecogénica lateral al ciego, con paredes finas y sin vascularización en estudio doppler-color. Imagen B: TC con contraste donde se observa una lesión localizada en FID, adyacente al ciego e independiente del apéndice cecal, de paredes bien definidas.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Gerard Rafart, Clara Bassaganyas, Xavier Morales, Míriam Cuatrecasas, Jordi Rimola" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Gerard" "apellidos" => "Rafart" ] 1 => array:2 [ "nombre" => "Clara" "apellidos" => "Bassaganyas" ] 2 => array:2 [ "nombre" => "Xavier" "apellidos" => "Morales" ] 3 => array:2 [ "nombre" => "Míriam" "apellidos" => "Cuatrecasas" ] 4 => array:2 [ "nombre" => "Jordi" "apellidos" => "Rimola" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2444382424000555" "doi" => "10.1016/j.gastre.2024.04.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382424000555?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570523003254?idApp=UINPBA00004N" "url" => "/02105705/0000004700000004/v2_202406091228/S0210570523003254/v2_202406091228/es/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Ischemic colitis due to Kayexalate crystals" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">Dear Editor</span>," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "391" "paginaFinal" => "392" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Berta Lopez-Saez, Alex Casalots, Eva Ballesteros, Eduard Brunet-Mas" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Berta" "apellidos" => "Lopez-Saez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Alex" "apellidos" => "Casalots" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Eva" "apellidos" => "Ballesteros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:4 [ "nombre" => "Eduard" "apellidos" => "Brunet-Mas" "email" => array:1 [ 0 => "ebrunetm@tauli.cat" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servei Aparell Digestiu, Hospital Universitari Parc Taulí, Sabadell, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departament de Patologia, Consorci del Laboratoi Intercomarcal de l’Alt Penedes, Anoia i el Garraf, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servei de Radiologia, Hospital Universitari Parc Taulí, Sabadell, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "CIBERehd, Instituto de Salud Carlos III, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Colitis isquémica por cristales de kayexalato" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1862 "Ancho" => 2417 "Tamanyo" => 748598 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Cecum and ascending colon wall thickening in CT scan. (b) Endoscopic ulcers at cecum, ileocecal valve. (c) Ulcerated areas, observing fibrinoleukocyte material and granulation tissue with Kayexalate crystals. (d) Kayexalate crystals amplified in size.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hyperkalaemia is an electrolyte disorder that can result in fatal cardiac arrhythmias. Sodium polystyrene sulfonate (Kayexalate) and calcium polystyrene sulfonate (Kalimate) are cation exchange resins indicated for the treatment of hyperkalaemia (doses of 15–45<span class="elsevierStyleHsp" style=""></span>mg per day with variable duration depending on the cause of hyperkalaemia) whose action takes place in the colon exchanging sodium/calcium and potassium accelerating potassium removal in the stool.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although these resins are widely used, important ischemic gastrointestinal adverse effects (mainly in colon 76.3%), have been described with an incidence of 1.8%.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The most frequent symptoms are abdominal pain (68.6%) and gastrointestinal bleeding (55.8%).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> We report the case of a patient with ischemic colitis due to Kayexalate treatment.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 74-year-old man with a history of ischemic heart disease, heart failure and chronic kidney disease (CKD), who was admitted to the emergency department due to polytrauma caused by a hit-and-run car accident. The patient required admission to semi-critical care due to multiple bone fractures associated with respiratory failure and exacerbation of his CKD with hyperkalaemia up to 7<span class="elsevierStyleHsp" style=""></span>mEq/L receiving prolonged treatment with sodium polystyrene sulfonate.</p><p id="par0020" class="elsevierStylePara elsevierViewall">During the first month of admission, the patient presents progressive anemia requiring blood transfusion every 1–2 days. Initially, anemia was attributed to blood loss due to multiple fractures and CKD, several abdominal CT scans were performed showing a cecum and ascending colon wall thickening without intra-abdominal bleeding (see <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Six weeks after admission, the patient presented rectal bleeding with anemia (hemoglobin 57<span class="elsevierStyleHsp" style=""></span>g/L) without hemodynamic instability. Colonoscopy was performed, observing longitudinal ulcers at cecum, ileocecal valve and ascending colon (see <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b). Biopsies were taken from the ulcerated areas, observing fibrinoleukocyte material and granulation tissue with crystalloid structures of rhomboid morphology compatible with Kayexalate crystals (see <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>c and d). Patient finally required up to 16 transfusions.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The endoscopic and histologic findings suggested an ischemic colitis due to sodium polystyrene sulfonate treatment used for hyperkalaemia. Our patient had received this treatment on several occasions during admission, especially the last week prior to the episode of rectal bleeding because of acute renal failure and hyperkalaemia. The resin was withdrawn and the patient presented a good clinical evolution without new episodes of rectal bleeding and with progressive correction of the anemia.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Gastrointestinal involvement produced by Kayexalate and Kalimate resins are more frequent in patients with CKD. In these patients there is an increase in renin levels that activate the angiotensin II pathway, producing vasoconstriction and consequently increasing the risk of non-occlusive mesenteric ischemia. The risk may also increase in those patients with paralytic ileus and/or distension of the colon, which produces a decrease in blood flow.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Treatment with Kayexalate and Kalimate often causes constipation, so it is usually associated with treatment with laxatives (usually sorbitol). It has been described that sorbitol can cause direct damage to the intestinal mucosa due to vasospasm and elevation of prostaglandins, which can cause vascular damage. Even so, numerous case series have shown that gastrointestinal adverse effects are related to the use of Kayexalate and Kalimate independently of the use of sorbitol.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Histology showed inflammation, ulceration and necrosis, so it can raise doubts with other gastrointestinal pathologies such as infectious colitis, ischemic colitis or inflammatory bowel disease. The visualization of the Kayexalate and Kalimate crystals, together with the clinical history, is mandatory to reach the diagnosis. Kayexalate crystals are identified in 95.5% of the cases and present a mosaic pattern and a rectangular shape reminiscent of “fish scales”. Crystals stain purple on hematoxylin–eosin staining, magenta on PAS/D, and black on acid fast stains.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, our patient was admitted in the ICU on absolute rest due to bone fractures when he received treatment with sodium polystyrene sulfonate (Kayexalate) for hyperkalaemia secondary to decompensation of his CKD, presenting severe rectal bleeding, observing deep colonic ulcers in the colonoscopy. Kayexalate crystals were found in the specimens; confirming the diagnosis of ischemic colitis due to Kayexalate crystals. After withdrawing the treatment with the resins, the patient presented a good clinical evolution.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Berta Lopez-Saez and Eduard Brunet reviewed the case and the available literature data and wrote the manuscript. Alex Casalots provides the figures. Berta Lopez-Saez, Alex Casalots and Eduard Brunet critically reviewed the text and provided important intellectual content. All authors definitively approved the submitted version.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contributions" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The patient has given his informed consent to publish the information included in the article.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1862 "Ancho" => 2417 "Tamanyo" => 748598 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Cecum and ascending colon wall thickening in CT scan. (b) Endoscopic ulcers at cecum, ileocecal valve. (c) Ulcerated areas, observing fibrinoleukocyte material and granulation tissue with Kayexalate crystals. (d) Kayexalate crystals amplified in size.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gastrointestinal adverse events with sodium polystyrene sulfonate (Kayexalate) use: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Z. Harel" 1 => "S. Harel" 2 => "P.S. Shah" 3 => "R. Wald" 4 => "J. Perl" 5 => "C.M. Bell" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Med" "fecha" => "2013" "volumen" => "126" "paginaInicial" => "9" "paginaFinal" => "16" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intestinal necrosis associated with postoperative orally administered sodium polystyrene sulfonate in sorbitol" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B.B. Gerstman" 1 => "R. Kirkman" 2 => "R. Platt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0272-6386(12)80544-0" "Revista" => array:6 [ "tituloSerie" => "Am J Kidney Dis" "fecha" => "1992" "volumen" => "20" "paginaInicial" => "159" "paginaFinal" => "161" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1496969" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adverse gastrointestinal effects with Kayexalate or Kalimate: a comprehensive review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Y.H. Wu" 1 => "J.W. Chou" 2 => "H.C. Lai" 3 => "G.S. Su" 4 => "K.S. Cheng" 5 => "T.W. Chen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2147/CEG.S278812" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Gastroenterol" "fecha" => "2021" "volumen" => "14" "paginaInicial" => "1" "paginaFinal" => "18" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33469334" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sodium polystyrene sulfonate and cytomegalovirus-associated hemorrhagic duodenitis: more than meets the eye" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. Gürtler" 1 => "P. Hirt-Minkowski" 2 => "S.S. Brunner" 3 => "K. König" 4 => "K. Glatz" 5 => "D. Reichenstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.12659/AJCR.910655" "Revista" => array:6 [ "tituloSerie" => "Am J Case Rep" "fecha" => "2018" "volumen" => "19" "paginaInicial" => "912" "paginaFinal" => "916" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30072684" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Colonic necrosis in a young patient receiving oral Kayexalate in sorbitol: case report and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Y.H. Chou" 1 => "H.Y. Wang" 2 => "M.S. Hsieh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.kjms.2010.12.010" "Revista" => array:6 [ "tituloSerie" => "Kaohsiung J Med Sci" "fecha" => "2011" "volumen" => "27" "paginaInicial" => "155" "paginaFinal" => "158" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21463839" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/02105705/0000004700000004/v2_202406091228/S0210570523004752/v2_202406091228/en/main.assets" "Apartado" => array:4 [ "identificador" => "9010" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas al Director" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/02105705/0000004700000004/v2_202406091228/S0210570523004752/v2_202406091228/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570523004752?idApp=UINPBA00004N" ]
