Corresponding author at: Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, ul. Banacha 1a, 02-097 Warsaw, Poland.
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Desai, Tun Jie, Jen-Jung Pan" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Avin" "apellidos" => "Aggarwal" ] 1 => array:2 [ "nombre" => "Rilwan" "apellidos" => "Balogun" ] 2 => array:2 [ "nombre" => "Tara F." "apellidos" => "Carr" ] 3 => array:2 [ "nombre" => "Archita P." 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Banacha 1a, 02-097 Warsaw, Poland." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1803 "Ancho" => 2083 "Tamanyo" => 441218 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(a) <span class="elsevierStyleItalic">Gyromitra esculenta</span>, “false morel”. (b) <span class="elsevierStyleItalic">Morchella esculenta</span>, “true morel”.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">1</span><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Among thousands of mushroom species that are found all over the world, approximately one hundred are poisonous to humans. Most of them cause mild symptoms, such as gastrointestinal disturbances like nausea, vomiting, diarrhea, or other manifestations like fever, muscle pain and a headache. Poisonous mushroom ingestion could also result in severe, life-threatening toxicity <a class="elsevierStyleCrossRef" href="#bib0100">[1]</a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Acute liver failure (ALF) manifests with abnormal liver functions with impaired coagulation (INR >1.5) and signs of encephalopathy, and manifestations of the latter could be up to 24 weeks from onset of illness in a patient with no previous history of liver disease. Whereas the term of acute liver injury (ALI) refers to patients with coagulopathy and no signs of encephalopathy <a class="elsevierStyleCrossRefs" href="#bib0105">[2,3]</a>. Its occurrence following <span class="elsevierStyleItalic">Amanita phalloides</span> mushroom poisoning is well known with the associated morbidity, mortality and often the need for liver transplantation in a significant proportion of cases. However, ALF due to <span class="elsevierStyleItalic">Gyromitra esculenta</span> mushrooms ingestion is less well reported.</p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">G. esculenta</span>, also known as a “false morel” (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a), is well documented as one of the most poisonous mushrooms. This species grow all over the world mostly in coniferous forests in early spring time. The mushroom is of medium size (5 up to 16<span class="elsevierStyleHsp" style=""></span>cm) with a typical irregular ‘brain-shaped’ cap (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). Unfortunately, “false morel” is easily confused with <span class="elsevierStyleItalic">Morchella esculenta</span> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b), which is known as a “true morel” and an exclusive culinary product <a class="elsevierStyleCrossRef" href="#bib0115">[4]</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Herein, we describe a case of acute liver injury, a case of ALF and an additional case of acute-on-chronic liver failure (ACLF) due to <span class="elsevierStyleItalic">G. esculenta</span> poisoning. Two patients recovered following typical medical treatment while a patient with acute-on-chronic liver failure died.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2</span><span class="elsevierStyleSectionTitle" id="sect0020">Case 1 – acute liver injury</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 61-year-old male patient was admitted to our unit in April 2014, two days after eating “brain-like” mushrooms. The patient experienced abdominal pain two days after the mushroom ingestion and this was associated with vomiting, intense watery diarrhea, and on admission was jaundiced. There were no signs of encephalopathy. Laboratory tests confirmed ALI (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Abdominal ultrasound showed signs of minor liver enlargement. Following supportive medical treatment the liver functions improved. The patient was discharged home 9 days after admission.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3</span><span class="elsevierStyleSectionTitle" id="sect0025">Case 2 – acute liver failure</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 67-year-old male patient was admitted to our Unit in April 2016 with signs of abdominal pain, fever, headache and jaundice that were followed by altered mentation. This occurred three days after ingestion of mushrooms, which the patient described as being very similar to “true morels”. The patient was irritable, mildly confused and found to be jaundiced with a tender right upper quadrant of abdomen. Laboratory blood tests confirmed acute liver failure (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) and the patient had signs of encephalopathy grade 3 according to West Haven Criteria <a class="elsevierStyleCrossRef" href="#bib0120">[5]</a>. The patient continued to deteriorate despite supportive care and required listing for a liver transplantation. The decision for liver transplantation was based primarily on rapidity and severity of deterioration even though the patient did not fulfill all of the Kings College criteria <a class="elsevierStyleCrossRef" href="#bib0125">[6]</a> for listing in fulminant hepatic failure. The clinical picture however stabilized and there was improvement noted in the 48<span class="elsevierStyleHsp" style=""></span>h that followed resulting in the patient being taken off the waiting list for a transplant. After eleven days of continued medical treatment, the patient improved to be discharged home with liver function tests normalized.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4</span><span class="elsevierStyleSectionTitle" id="sect0030">Case 3 – acute-on-chronic liver failure</span><p id="par0035" class="elsevierStylePara elsevierViewall">A 59-year-old man with a history of HCV hepatitis (untreated, diagnosed in 2002) and diabetes presented in April 2016, three days after eating mushrooms, which his family described as a “false morel”. A few hours after ingestion symptoms including muscle pain with vomiting and diarrhea were observed. At admission he had grade 3 encephalopathy. The patient rapidly developed multi-organ failure requiring inotrope support, invasive ventilator support and hemodialysis (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). He also required glucose infusion to maintain normoglycemia. He received a standard treatment with intravenous colloids, crystalloids and glucose. His encephalopathy was treated with intravenous <span class="elsevierStyleSmallCaps">l</span>-ornithine <span class="elsevierStyleSmallCaps">l</span>-aspartate. The abdominal ultrasound revealed enlarged and heterogenous liver parenchyma with no signs of portal hypertension and normal spleen. The patient did not however fulfill the Kings College criteria <a class="elsevierStyleCrossRef" href="#bib0125">[6]</a>. Despite signs of continued deterioration of liver function the option of liver transplantation was not considered feasible due to established multi-organ failure. The patient died 5 days following mushroom ingestion.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5</span><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">There are various types of wild mushrooms growing in forests, which are often eaten by foragers. Only about 2% (out of more than 5000 species that are found worldwide) are poisonous. This includes <span class="elsevierStyleItalic">G. esculenta</span>, so called “false morel” <a class="elsevierStyleCrossRef" href="#bib0130">[7]</a>. Herein, we describe the clinical course of three patients to emphasize variable symptoms of poisoning.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The poisoning with <span class="elsevierStyleItalic">G. esculenta</span> should be considered and differentiated from other causes of toxic liver failure which occur in the spring time, as opposed to <span class="elsevierStyleItalic">A. phalloides</span> occurring in autumn. It is also not typically shaped with a stem and a cap <a class="elsevierStyleCrossRefs" href="#bib0135">[8,9]</a>.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The manifestations of poisoning following ingestion of <span class="elsevierStyleItalic">G. esculenta</span> usually occur around 12<span class="elsevierStyleHsp" style=""></span>h following ingestion with gastrointestinal symptoms followed by jaundice within 2–3 days and significant increase of AST, ALT and INR with a degree of encephalopathy. There is a paucity of reported publications of poisoning following ingestion of <span class="elsevierStyleItalic">G. esculenta</span>, limited to a few case reports <a class="elsevierStyleCrossRefs" href="#bib0145">[10,11]</a>. In these too most patients described failed to fulfill criteria for ALF or even ALI, with moderate transaminitis being the main feature. However, fatal cases have also been reported <a class="elsevierStyleCrossRef" href="#bib0155">[12]</a>. The toxin gyromytrin, chemically identified as an N-methyl-N-formylhydrazone is a water soluble compound that evaporates easily at normal temperatures <a class="elsevierStyleCrossRef" href="#bib0160">[13]</a>. The toxin could be therefore partially deactivated or even eliminated by cooking or drying. However partial cooking could lead to hydrolyzation which could also be caused by the acidity of the stomach following ingestion, to the direct toxin-monomethylhydrazine (MMH). Metabolic intermediates of gyromytrin toxin-free methyl radical and an unstable diazonium compound, which arises after oxidation from MMH damage hepatocytes, causing their necrosis and interfere with cytochrome enzymes (mainly P450), aminooxidases and glutathione pathways <a class="elsevierStyleCrossRef" href="#bib0165">[14]</a>. This may be combined with a degree of neurotoxicity by modulating pyridoxine dependent coenzymes, therefore having influence on gamma-aminobutyric acid (GABA) levels <a class="elsevierStyleCrossRef" href="#bib0170">[15]</a>.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The three patients described developed liver disfunction of varied severity following <span class="elsevierStyleItalic">G. esculenta</span> poisoning. Our report highlights the possibility <span class="elsevierStyleItalic">G. esculenta</span> ingestion may cause an acute liver failure. It is likely that in subjects with underlying or preexistent liver dysfunction the course may be very aggressive with death a likely outcome.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Described cases show limited utility of widely used criteria selecting patient with urgent need of transplantation <a class="elsevierStyleCrossRef" href="#bib0125">[6]</a>. This reinforces the need to develop new prognostic or diagnostic tests of high sensitivity and specificity that would allow adequate placing patients on high urgency waiting list for liver transplantation.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The clinical indications for emergency liver transplantation are commonly based on the King's College Hospital Criteria or Clichy criteria <a class="elsevierStyleCrossRef" href="#bib0125">[6]</a>. However, their sensitivity and specificity in patients with ALF due to some rare causes are not clearly specified. The utility of Kings College criteria has previously been evaluated in case of <span class="elsevierStyleItalic">A. phalloides</span> poisoning. Interestingly, the sensitivity of only 25% with 80% specificity of predicting poor outcome in case of amatoxin induced ALF have been reported <a class="elsevierStyleCrossRef" href="#bib0175">[16]</a>. This contradicts with a series reported by Escudie et al. <a class="elsevierStyleCrossRef" href="#bib0180">[17]</a> who reported Kings College sensitivity and specificity of 100% each in case of <span class="elsevierStyleItalic">A. phalloides</span> poisoning. According to Ganzert et al. <a class="elsevierStyleCrossRef" href="#bib0185">[18]</a>, the combination of serum creatinine above 106<span class="elsevierStyleHsp" style=""></span>μmol/L and PT index less than 25% strongly suggests the urgent need for liver transplantation <a class="elsevierStyleCrossRef" href="#bib0185">[18]</a>.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Some parameters may also be helpful in predicting prognosis, among them proven factors of poor outcome are: encephalopathy and kidney impairment <a class="elsevierStyleCrossRef" href="#bib0180">[17]</a>, lactic acidosis, especially when observed with coexisting hepatic encephalopathy <a class="elsevierStyleCrossRef" href="#bib0190">[19]</a>, time interval shorter than 8<span class="elsevierStyleHsp" style=""></span>h between eating mushrooms and the occurrence of first symptoms (such as vomiting or diarrhea <a class="elsevierStyleCrossRef" href="#bib0175">[16]</a>. Nevertheless, majority of prognostic factors following mushroom intoxication refer to <span class="elsevierStyleItalic">A. phalloides</span> poisoning. In comparison however there is less known about <span class="elsevierStyleItalic">G. esculenta</span> poisoning to help with prognostication.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In summary, <span class="elsevierStyleItalic">G. esculenta</span> poisoning represents a rare but potentially dangerous clinical scenario that should always be considered in the spring time in regions it is found. Given the limited sensitivity and specificity of currently available prognostic criteria, such patients should preferably be transferred to liver transplant and hepatology units early. Efforts should be made to develop more precise and sensitive prognostic criteria that could help clinicians in selecting the patients for liver transplantation.<span class="elsevierStyleDefList"><span class="elsevierStyleSectionTitle" id="sect0040">Abbreviations</span><span class="elsevierStyleDefTerm">ACLF</span><span class="elsevierStyleDefDescription"><p id="par0080" class="elsevierStylePara elsevierViewall">acute-on-chronic liver failure</p></span><span class="elsevierStyleDefTerm">ALF</span><span class="elsevierStyleDefDescription"><p id="par0085" class="elsevierStylePara elsevierViewall">acute liver failure</p></span><span class="elsevierStyleDefTerm">ALI</span><span class="elsevierStyleDefDescription"><p id="par0090" class="elsevierStylePara elsevierViewall">acute liver failure</p></span><span class="elsevierStyleDefTerm">INR</span><span class="elsevierStyleDefDescription"><p id="par0095" class="elsevierStylePara elsevierViewall">international normalized ratio</p></span><span class="elsevierStyleDefTerm">GABA</span><span class="elsevierStyleDefDescription"><p id="par0100" class="elsevierStylePara elsevierViewall">gamma-aminobutyric acid</p></span><span class="elsevierStyleDefTerm">MMH</span><span class="elsevierStyleDefDescription"><p id="par0105" class="elsevierStylePara elsevierViewall">monomethylhydrazine</p></span></span></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">Nothing to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1199047" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1117487" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 1 – acute liver injury" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 2 – acute liver failure" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 3 – acute-on-chronic liver failure" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-07-28" "fechaAceptado" => "2018-11-28" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1117487" "palabras" => array:3 [ 0 => "Acute liver failure" 1 => "Mushroom poisoning" 2 => "<span class="elsevierStyleItalic">Gyromitra esculenta</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Gyromitra esculenta</span>, also known as “false morel” is one of the most poisonous mushrooms. This species is found all over the world, growing in coniferous forest in early spring time. Common manifestation of poisoning includes gastrointestinal symptoms which include varied degrees of liver impairment.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We describe three cases: acute liver injury, acute liver failure and acute-on-chronic liver failure due to <span class="elsevierStyleItalic">G. esculenta</span> poisoning. At admission patients presented with encephalopathy and features of liver failure. Two of them recovered completely following supportive management while the remaining patient who also had preexisting liver disease developed multiorgan failure and subsequently died.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Although a rare occurrence, <span class="elsevierStyleItalic">G. esculenta</span> poisoning should be considered in the differential diagnosis of acute liver failure.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1803 "Ancho" => 2083 "Tamanyo" => 441218 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(a) <span class="elsevierStyleItalic">Gyromitra esculenta</span>, “false morel”. (b) <span class="elsevierStyleItalic">Morchella esculenta</span>, “true morel”.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Normal ranges: AST 5–40<span class="elsevierStyleHsp" style=""></span>U/L; ALT 7–56<span class="elsevierStyleHsp" style=""></span>U/L; INR 0.9–1.3; total bilirubin 0.2–1.2<span class="elsevierStyleHsp" style=""></span>mg/dL; serum creatinine 0.6–1.2<span class="elsevierStyleHsp" style=""></span>mg/dL; encephalopathy grade West Heaven 0–4.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: ALT, alanine transaminase; AST, aspartate aminotransferase; S.cr, serum creatine; INR, international normalized ratio.</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="" 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">Age \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">Gender \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">AST IU/L \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">ALT IU/L \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">S. cr mg/dL \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">Bilirubin mg/dL \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">INR \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">Encephalopathy grade \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">Outcome \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">Case 1 \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">61 \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">Male \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">1032 \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">2248 \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">0.7 \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">14.85 \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">1.65 \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 \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">Alive \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">Case 2 \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 \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">Male \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">2422 \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">2657 \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">1.67 \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">5.68 \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">2.72 \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 \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">Alive \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">Case 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">59 \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">Male \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">7605 \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">5183 \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">2.8 \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">10.42 \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">3.8 \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 \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">Dead \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2047871.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A comparison of laboratory features at admission between three cases after <span class="elsevierStyleItalic">Gyromitra esculenta</span> poisoning.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "[1]" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mushrooms" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H. 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Year/Month | Html | Total | |
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2024 November | 11 | 0 | 11 |
2024 October | 41 | 5 | 46 |
2024 September | 66 | 4 | 70 |
2024 August | 54 | 3 | 57 |
2024 July | 55 | 9 | 64 |
2024 June | 50 | 3 | 53 |
2024 May | 65 | 5 | 70 |
2024 April | 63 | 5 | 68 |
2024 March | 121 | 18 | 139 |
2024 February | 84 | 6 | 90 |
2024 January | 51 | 2 | 53 |
2023 December | 66 | 6 | 72 |
2023 November | 54 | 12 | 66 |
2023 October | 85 | 4 | 89 |
2023 September | 51 | 5 | 56 |
2023 August | 63 | 6 | 69 |
2023 July | 54 | 21 | 75 |
2023 June | 75 | 2 | 77 |
2023 May | 136 | 13 | 149 |
2023 April | 128 | 4 | 132 |
2023 March | 99 | 8 | 107 |
2023 February | 72 | 6 | 78 |
2023 January | 66 | 11 | 77 |
2022 December | 77 | 9 | 86 |
2022 November | 161 | 9 | 170 |
2022 October | 112 | 11 | 123 |
2022 September | 159 | 13 | 172 |
2022 August | 151 | 18 | 169 |
2022 July | 162 | 19 | 181 |
2022 June | 98 | 12 | 110 |
2022 May | 107 | 13 | 120 |
2022 April | 189 | 19 | 208 |
2022 March | 312 | 39 | 351 |
2022 February | 327 | 23 | 350 |
2022 January | 320 | 38 | 358 |
2021 December | 288 | 40 | 328 |
2021 November | 317 | 40 | 357 |
2021 October | 358 | 26 | 384 |
2021 September | 328 | 35 | 363 |
2021 August | 318 | 22 | 340 |
2021 July | 346 | 29 | 375 |
2021 June | 228 | 22 | 250 |
2021 May | 316 | 43 | 359 |
2021 April | 778 | 57 | 835 |
2021 March | 494 | 41 | 535 |
2021 February | 321 | 32 | 353 |
2021 January | 311 | 24 | 335 |
2020 December | 282 | 30 | 312 |
2020 November | 271 | 34 | 305 |
2020 October | 238 | 27 | 265 |
2020 September | 306 | 28 | 334 |
2020 August | 263 | 26 | 289 |
2020 July | 239 | 23 | 262 |
2020 June | 255 | 29 | 284 |
2020 May | 217 | 19 | 236 |
2020 April | 153 | 20 | 173 |
2020 March | 100 | 10 | 110 |
2020 February | 49 | 5 | 54 |
2020 January | 39 | 4 | 43 |
2019 December | 41 | 4 | 45 |
2019 November | 16 | 4 | 20 |
2019 October | 15 | 0 | 15 |
2019 September | 22 | 4 | 26 |
2019 August | 11 | 3 | 14 |
2019 July | 15 | 12 | 27 |
2019 June | 20 | 24 | 44 |
2019 May | 21 | 22 | 43 |