Original article
Single-center, double-blind, randomized, placebo-controlled pilot study of Canoxidin® for prevention of catheter encrustation in patients with indwelling catheters
Estudio piloto unicéntrico, doble ciego, aleatorizado y controlado con placebo para evaluar el uso de Canoxidin® en la prevención de la incrustación de la sonda en pacientes portadores de sonda permanente
A. Boraua,
, E. Amayaa, P. Delíaa, M.J. Alvesb, M. Morcilloc, A. Ustrellc, E. Opissod
Corresponding author
a Servicio de Neurourología, Institut Guttmann, Badalona, Barcelona, Spain
b Servicio de Urología, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
c Área de Enfermería, Institut Guttmann, Badalona, Barcelona, Spain
d Oficina de Innovación e Investigación, Institut Guttmann, Badalona, Barcelona, Spain
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Borau, E. Amaya, P. Delía, M.J. Alves, M. Morcillo, A. Ustrell, E. Opisso" "autores" => array:7 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Borau" "email" => array:1 [ 0 => "aborau31@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "Amaya" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Delía" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M.J." "apellidos" => "Alves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Morcillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Ustrell" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 6 => array:3 [ "nombre" => "E." "apellidos" => "Opisso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Neurourología, Institut Guttmann, Badalona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Urología, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Área de Enfermería, Institut Guttmann, Badalona, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Oficina de Innovación e Investigación, Institut Guttmann, Badalona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio piloto unicéntrico, doble ciego, aleatorizado y controlado con placebo para evaluar el uso de Canoxidin® en la prevención de la incrustación de la sonda en pacientes portadores de sonda permanente" ] ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0030" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 830 "Ancho" => 1333 "Tamanyo" => 200772 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with urinary incontinence and retention often require indwelling catheter implantation. The prevalence of Foley catheter use can reach 20% in hospitalized patients.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Patients with long-term catheters have an increased risk of developing severe or chronic disease and disability.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Currently, there is no standard strategy for preventing catheter encrustation and blockage in patients with indwelling catheters. Several anti-fouling, biocidal, and anti-adhesive approaches have been tested to prevent biofilm formation, bacterial colonization, and subsequent catheter obstruction; however, most of these preventive measures have been disappointing in clinical use.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Another approach is the use of irrigation solutions with the Uro-Tainer® bags for catheter rinses,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> but high-quality clinical trials are needed to demonstrate the therapeutic effects of these solutions. One reason for encrustation is the increased pH, which causes calcium and magnesium ions to deposit on the biofilm.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Therefore, catheter encrustation could be minimized by altering the urine composition through increased urine acidification and urinary excretion of crystallization inhibitors. These interventions can significantly increase catheter patency by approximately one month in neuro-urological patients and improve the safety of catheter implantation.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–12</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Canoxidin® is an oral treatment initially developed to prevent encrustation of catheters. It consists of L-methionine (500 mg/tablet), a urine acidifier,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and two crystallization inhibitors: phytate (144.5 mg/tablet), which prevents calcium oxalate and phosphate crystallization,<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> and theobromine (60 mg/tablet), which inhibits uric acid crystallization.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The combination of L-methionine and phytate has been evaluated in a randomized, double-blinded, and placebo-controlled trial that enrolled patients with indwelling double J stents. The participants were treated for 3 to 8 weeks depending on the time interval between the baseline visit and stent removal, and the intervention group showed a lower global encrustation rate of stent ends than the placebo group, with reductions of the overall crust by eight times and greater pH reduction of the urine.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In the present study, we aimed to examine the effects of Canoxidin® on catheter encrustation in patients with indwelling Foley catheters, both in the upper part (bladder balloon end) and lower part (collection bag end) of the catheter.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design and participants</span><p id="par0015" class="elsevierStylePara elsevierViewall">We performed a single-center, double-blind, randomized, placebo-controlled, pilot study. Eligible participants were screened and recruited at the Neuro-urology service. They had to be 18 years or older and require an indwelling catheter (urethral or suprapubic) for bladder emptying. The exclusion criteria were active urinary infection (clinically diagnosed); use of a local estrogen, antibiotic, prebiotic, or probiotic; consumption of blueberries, cranberries, or any treatment to reduce the recurrence of urinary infection, including supplements rich in phytate or its different salts, or citrates in the form of magnesium salts during the three weeks prior to study onset; suspected metabolic acidosis; estimated glomerular filtration rate below 30 mL/min; an inflammatory disease of the urinary tract not caused by bacterial infection (radical cystitis, bladder pain syndrome, BCG cystitis); pregnancy; active renal or bladder lithiasis; a known disorder or disease of the urinary tract that is incompatible with the proposed treatment; life expectancy of less than 12 months; coexistence of a hematological or immunological disease or use of an immunotherapeutic drug that may interfere with the immune response; allergy to any of the ingredients of the experimental product or placebo; and P and Mg levels of 50 µmol or more in the catheter implanted before treatment (catheter 1). The patients were randomized (1:1) to active treatment or placebo groups. Patients in each group were instructed to take 3 tablets per day (8-h intervals) of Canoxidin® or matched-placebo for 1 month, respectively.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The protocol of the study was approved by the Ethics Committee for Research with Medicines (CEIm) of the Fundació Unió Catalana d’Hospitals (CEI 20/82). All the participants provided written informed consent.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Assessment of catheter encrustation</span><p id="par0025" class="elsevierStylePara elsevierViewall">The catheters were removed 1 month after placement (2 per patient: 1 before treatment and 1 after treatment). Two fragments (2 cm each) were sampled and analyzed from each catheter: one close to the urine collection bag and the other close to the urinary bladder. Each 2 cm fragment was photographed using stereoscopic microscopy. The type of embedded deposit was identified by scanning electron microscopy (SEM, Hitachi S-3400 N, Tokyo, Japan) coupled with X-ray microanalysis (Bruker AXS Xflash Detector 4010, Berlin, Germany). The results were characterized as no deposit, calcium oxalate deposit, infectious phosphate (magnesium ammonium phosphate + hydroxyapatite) deposit, or non-infectious phosphate (hydroxyapatite + brushite) deposit.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally, each 2 cm fragment was treated with 2 M HCl to dissolve the deposit and determine the total amounts of calcium, phosphorus, and magnesium using inductively coupled plasma optical emission spectroscopy (ICP-OES).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Outcomes and data analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">The primary endpoints were the presence and degree of encrustation (0, null; 1, low; 2, medium; 3, complete blockage) in the upper part (bladder balloon area) and the lower part (collection bag area) of the catheter. Improvement was defined as a decrease of more than 75 µmol in magnesium ammonium phosphate (P and Mg) or hydroxyapatite/calcium oxalate (Ca and P) deposits in catheter 2 (after treatment) compared with catheter 1 (before treatment), according to previous experience of the analysts of the renal lithiasis research group of the University of the Balearic Islands.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The secondary endpoints were changes in the composition and structural characteristics of encrustations in the upper and lower parts of the catheter, adherence to treatment, adverse events attributable to the treatment or study recommendations, and investigator and patient satisfaction with preventive therapy.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Inter-group comparisons were performed using one-factor analysis of variance (ANOVA), Mann-Whitney U test, and Pearson’s chi-square test. Intra-group comparisons were performed using a repeated-measures <span class="elsevierStyleItalic">t</span>-test and the Wilcoxon test. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported, and a P-value below 0.05 was considered significant. Statistical analyses were performed using SPSS v26.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">Forty patients were screened and randomized. Based on the inclusion and exclusion criteria, 28 participants were included in this study. Of these, 13 were assigned to the active treatment group and 15 were assigned to the placebo group. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the demographic and clinical characteristics of the participants. All but one patient required catheterization for neurogenic bladder dysfunction due to spinal cord injury. Fifty-six Foley catheters from the 28 patients with an indwelling time of one month were examined.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Two patients in the placebo group and 8 patients in the Canoxidin® group experienced an improvement (less encrustation), and 13 patients in the placebo group and 5 patients in the Canoxidin® group experienced no improvement (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The χ<span class="elsevierStyleSup">2</span> test showed that there was a significant association between Canoxidin® and improvement (OR: 10.4, 95% CI: 1.6 to 66.9, P = 0.016). Based on the incidence of improvement in each group, the number needed to treat (NNT) was 1.56.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The analysis of the 8 patients treated with Canoxidin® who had an improvement demonstrated significant decreases in the levels of P (p = 0.012) and Ca (p = 0.05) in catheter 2 compared to catheter 1. There was a trend for decreased levels of Mg, but the difference was not significant (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Catheter 2 also had a significantly lower total level of Ca + P + Mg (p = 0.012). After removal of catheter 2, we confirmed 12 (80%) urinary tract infections in the placebo group and 8 (61.5%) infections in the Canoxidin® group (OR, 2.5; 95% CI: 0.46 to 13.52, p = 0.326). <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows examples of the four types of catheter fouling observed by SEM. Analysis of all 28 patients indicated that the types of deposits were similar for catheters 1 and 2 (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">We also compared the levels of different deposits in the upper and lower portions of the catheters removed from the 28 patients. All catheters had greater deposition of all three elements (Ca, P, and Mg) in the bladder part of the catheter than at the end of the collecting bag. However, all of these values had large variances, and the differences were not statistically significant (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The assessment of patient satisfaction using a 10-point scale indicated that the Canoxidin® group had an average satisfaction of 7.5 ± 1.5, and the placebo group had an average satisfaction of 7.3 ± 2.7 (p > 0.05). Average satisfaction rated by physicians was 9.1 ± 1.0 in the placebo group and 9.6 ± 0.7 in the Canoxidin® group (p > 0.05). No adverse effects attributable to the treatment were observed, and none of the patients experienced any adverse events.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Long-term catheterization is frequently associated with infections, bladder spasms, or catheter encrustations and blockages, and there is no definitive intervention to prevent encrustation and morbidity in patients with long-term indwelling catheters. The results of this randomized, placebo-controlled trial demonstrated that oral treatment with Canoxidin® reduced encrustation (at least 75 µmol) formed by Ca, P, and Mg after one month, compared with treatment with placebo. Moreover, patients who showed reduced encrustation had significant decreases in P (p = 0.012) and Ca (p = 0.05), a trend for decreased Mg, and a significant reduction in the total levels of Ca, P, and Mg (p = 0.012). These data indicated that a one-month regimen of Canoxidin® reduced the encrustation of indwelling Foley catheters implanted in patients with complex clinical conditions and recurrent infections.</p><p id="par0075" class="elsevierStylePara elsevierViewall">It has been reported that the presence of infection in urine and urine pH are important contributors to the development of encrustation.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Urinary sediment is formed by the precipitation of Ca, P, and Mg minerals in urine in the presence of urea-splitting bacteria, which elevates the urinary pH due to increased ammonium production. An alkaline pH facilitates the formation of a crystalline biofilm structure that protects the bacteria and makes the biofilm very difficult to eliminate.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> This crystalline mass formation can occlude bacteria and generate persistent urinary tract infections.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The components of Canoxidin® (phytate, L-methionine, and theobromine) can delay or prevent the multifactorial encrustation process to some degree. Specifically, the intake of InsP6 (phytate) leads to the excretion of a mixture of InsPs (InsP2, Insp3, InsP4, Insp5, InsP6) that inhibit the crystallization of calcium salts (calcium oxalates, brushites, hydroxyapatite).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Thus, in addition to preventing catheter encrustations, phytate consumption may also prevent bacterial colonization and the need for antibiotics.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22,23</span></a> L-methionine is a urine acidifier that can compensate for the over-alkalinization caused by urease-positive bacteria by preventing substances such as calcium phosphate from precipitating at this high pH.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Additionally, when bacteria are present in the urine, nitrates are degraded into nitrites, and an acidic medium facilitates the transformation of nitrites into nitrogen oxides, which are toxic to bacteria.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In fact, we found more urinary tract infections in the placebo group (80%) than in the Canoxidin® group (61%), although this difference was not statistically significant. Moreover, acidification with L-methionine may increase the efficacy of certain acidophilic antibiotics, such as nitrofurantoin or fosfomycin, which are commonly used to treat infections in these patients.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The last component, theobromine, is a uric acid crystal inhibitor that may be clinically useful in the treatment of uric acid nephrolithiasis.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In this case, theobromine is intended to act as a protective agent against possible over-acidification provoked by L-methionine; if urine pH drops below 5.5, precipitation of uric acid crystals on the catheter may occur, and this would be avoided with theobromine.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> As we did not determine the presence of uric acid crystals or uricosuria, this should be assessed and eventually confirmed in future studies. Moreover, although the combination of the three compounds of Canoxidin® seems effective, analyzing urinary composition and pH and the type of catheter encrustation could better inform the individualized treatment for a given patient, allowing for a more precise anti-fouling strategy.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Regarding the tolerability of Canoxidin®, both patients and health professionals rated their satisfaction with the treatment equally or slightly better than with the placebo, and none of the patients in either group experienced adverse effects attributable to the treatment. As a non-invasive method to prevent or reduce catheter encrustation, Canoxidin® seems a more convenient option than catheter rinses with Uro-Tainer® bags.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The major limitation of this study is that we examined only a small number of patients during a short follow-up period. Although it can be difficult to obtain positive results with such a small sample size, it was necessary to perform this pilot study before studying a larger number of patients.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusion</span><p id="par0095" class="elsevierStylePara elsevierViewall">This study of patients who had indwelling Foley catheters showed that a high percentage had catheter encrustation, with or without infection. The results also showed that Canoxidin®, a novel oral treatment that contains crystallization inhibitors and a urine acidifier, reduced the formation of encrustations with an excellent short-term safety profile. Further evaluation of the possible effects of Canoxidin® on urinary infections using a larger sample size is needed.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethics approval and consent to participate</span><p id="par0100" class="elsevierStylePara elsevierViewall">The study protocol was approved by the Ethics Committee for Research with Medicines of Fundació Unió Catalana d'Hospitals (CEI 20/82), and was performed in accordance with the Declaration of Helsinki. All patients provided written informed consent.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Funding</span><p id="par0105" class="elsevierStylePara elsevierViewall">The sponsor of this study was <span class="elsevierStyleGrantSponsor" id="gs0005">Devicare S.L.</span> The sponsor provided the study medications and funded the medical writing assistance.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interests</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no relevant financial or non-financial interests to disclose.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Author contributions</span><p id="par0115" class="elsevierStylePara elsevierViewall">All the authors contributed to the conception and design of the study. Coordination was performed by A Borau and Opisso E. Patient recruitment and data analysis were performed by Borau A, Almaya E, Delía P. Data collection were performed by Morcillo M and Ustrell A The first draft of the manuscript was written by Borau A. All authors have read and approved the final manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres2271203" "titulo" => "Graphical abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:3 [ "identificador" => "xres2271204" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec1893163" "titulo" => "Keywords" ] 3 => array:3 [ "identificador" => "xres2271205" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1893162" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design and participants" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Assessment of catheter encrustation" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Outcomes and data analysis" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0045" "titulo" => "Ethics approval and consent to participate" ] 11 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 12 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interests" ] 13 => array:2 [ "identificador" => "sec0060" "titulo" => "Author contributions" ] 14 => array:2 [ "identificador" => "xack781705" "titulo" => "Acknowledgments" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-03-15" "fechaAceptado" => "2024-05-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1893163" "palabras" => array:6 [ 0 => "Foley catheter" 1 => "Phytate" 2 => "Theobromine" 3 => "Methionine" 4 => "Catheter encrustation" 5 => "Prevention" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1893162" "palabras" => array:6 [ 0 => "Catéter Foley" 1 => "Fitato" 2 => "Teobromina" 3 => "Metionina" 4 => "Incrustación de la sonda" 5 => "Prevención" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction and objectives</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Long-term use of an indwelling catheter is associated with complications such as catheter encrustation and infection. Canoxidin® is a novel oral treatment that can potentially prevent catheter encrustation, as it contains a urine acidifier and a combination of two crystallization inhibitors. This study aimed to evaluate the effects of Canoxidin® on catheter encrustation in patients with indwelling Foley catheters.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patients and methods</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">This was a single-center, double-blind, randomized, placebo-controlled study. Neuro-urology patients aged ≥18 years with an indwelling catheter (urethral or suprapubic) were randomized to treatment consisting of either Canoxidin® or placebo for one month. Foley catheters (two per patient, one before treatment and one after treatment) were removed for analysis of the presence and degree of encrustation.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A total of 40 patients were enrolled and randomized, 28 of whom had analyzable catheters (13 assigned to Canoxidin® and 15 assigned to placebo). The patients had a mean age of 51.8 years, and eight (28.6%) were female. Two patients (13.3%) in the placebo group and eight patients (61.5%) in the Canoxidin® group experienced an improvement (less encrustation). There was a significant association between Canoxidin® and improvement (odds ratio: 10.4, 95% confidence interval: 1.6 to 66.9, P = 0.016). No adverse effects attributable to the treatment were reported.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The overall rate of catheter encrustation was high among those with indwelling Foley catheters. One-month treatment with Canoxidin® reduced the formation of these encrustations, with an excellent short-term safety profile.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducción y objetivos</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">El uso prolongado de una sonda se asocia a complicaciones como la incrustación y las infecciones. Canoxidin® es un novedoso tratamiento oral que puede prevenir la formación de incrustaciones sobre la sonda, ya que combina la acción de un acidificante de la orina con dos inhibidores de la cristalización. El objetivo de este estudio era evaluar los efectos de Canoxidin® en las incrustaciones de las sondas en pacientes portadores de catéter Foley de larga duración.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pacientes y métodos</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Se realizó un estudio unicéntrico, doble ciego, aleatorizado y controlado con placebo. Los pacientes neurourológicos de ≥18 años, portadores de una sonda permanente (uretral o suprapúbica) fueron asignados aleatoriamente a tratamiento con Canoxidin® o placebo durante un mes. Se retiraron las sondas (dos por paciente, una antes del tratamiento y otra después) para analizar la presencia y el grado de incrustación.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">En total se inscribieron 40 pacientes asignados aleatoriamente a tratamiento o placebo, 13 fueron asignados a Canoxidin® y 15 a placebo, y en 28 pacientes fue posible analizar la sonda. La edad media de los pacientes era de 51,8 años, y ocho (28,6%) eran mujeres. Dos pacientes (13,3%) del grupo placebo y ocho pacientes (61,5%) del grupo Canoxidin® presentaron una mejoría (menos incrustaciones). Hubo una asociación significativa entre Canoxidin® y la mejoría (odds ratio: 10,4; intervalo de confianza del 95%: 1,6 a 66,9; p = 0,016). No se notificaron efectos adversos atribuibles al tratamiento.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La tasa global de incrustación de la sonda fue elevada entre los pacientes portadores de catéter Foley permanente. El tratamiento de un mes con Canoxidin® redujo la formación de estas incrustaciones, con un excelente perfil de seguridad a corto plazo.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Borau A, Amaya E, Delía P, Alves MJ, Morcillo M, Ustrell A, et al. Estudio piloto unicéntrico, doble ciego, aleatorizado y controlado con placebo para evaluar el uso de Canoxidin® en la prevención de la incrustación del catéter en pacientes portadores de catéter permanente. Actas Urol Esp. 2024. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.acuro.2024.05.005">https://doi.org/10.1016/j.acuro.2024.05.005</span></p>" ] ] "multimedia" => array:7 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1201 "Ancho" => 1667 "Tamanyo" => 92759 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Outcomes of catheter encrustations in the two groups.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1510 "Ancho" => 2508 "Tamanyo" => 178905 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Micromoles of Ca, P, and Mg in catheter 1 and catheter 2 of all 8 patients treated with Canoxidin® whose catheters had reduced encrustation.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1250 "Ancho" => 1583 "Tamanyo" => 230822 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Representative deposits observed by scanning electron microscopy of the Foley catheters. (A) Thin layer of organic matter (no deposits). (B) Mixed calcium oxalate monohydrate/dihydrate deposits. (C) Hydroxyapatite deposits (no infection). (D) Ammonium and magnesium phosphate deposits (urolithic infections).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 859 "Ancho" => 2500 "Tamanyo" => 127777 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Types of deposits in catheters 1 and 2 in all 28 patients.</p>" ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 994 "Ancho" => 1508 "Tamanyo" => 73673 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Micromoles of Ca, P, and Mg in the upper (bladder) and lower (collecting bag) parts of catheters 1 and 2 in all 28 patients.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">CaUTI, Catheter-associated urinary tract infection; SD, Standard deviation; UTI, Urinary tract infection.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Placebo groupN = 15 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Canoxidin® groupN = 13 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years), mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51.6 (12.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52.0 (18.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex, females, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (20.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (38.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Months with permanent catheter, mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67.0 (93.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100.8 (53.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of catheter, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Urethral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (66.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (46.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Suprapubic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (53.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previous catheter encrustations, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (46.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (53.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complications associated with previous encrustations, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Full blockage/urinary retention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (40.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (38.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CaUTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (6.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pyelonephritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of UTIs in the previous 12 months, mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.0 (1.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 (1.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3688542.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Participants’ demographic and clinical characteristics.</p>" ] ] 6 => array:5 [ "identificador" => "fig0030" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 830 "Ancho" => 1333 "Tamanyo" => 200772 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence and risk factors of inappropriate use of intravenous and urinary catheters in surgical and medical patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "B.J. 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