Increased mortality from acute liver failure in Mexico
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"tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "263" "paginaFinal" => "264" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 688 "Ancho" => 1000 "Tamanyo" => 76668 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Contrast enhanced axial section showing aneurysmal dilatation of left branch of portal vein (arrows).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sameer Vyas, Divyesh Mahajan, Manavjeet Singh Sandhu, Ajay Duseja, Niranjan Khandelwal" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Sameer" "apellidos" => "Vyas" ] 1 => array:2 [ "nombre" => "Divyesh" "apellidos" => "Mahajan" ] 2 => array:2 [ "nombre" => "Manavjeet" "apellidos" => "Singh Sandhu" ] 3 => array:2 [ "nombre" => "Ajay" "apellidos" => "Duseja" ] 4 => array:2 [ "nombre" => "Niranjan" "apellidos" => "Khandelwal" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119310336?idApp=UINPBA00004N" "url" => "/16652681/0000001100000002/v1_201906150950/S1665268119310336/v1_201906150950/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1665268119310312" "issn" => "16652681" "doi" => "10.1016/S1665-2681(19)31031-2" "estado" => "S300" "fechaPublicacion" => "2012-03-01" "aid" => "70787" "copyright" => "Fundación Clínica Médica Sur, A.C." "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Ann Hepatol. 2012;11:249-56" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 78 "formatos" => array:3 [ "EPUB" => 12 "HTML" => 33 "PDF" => 33 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "A comparison study of local injection and radiofrequency ablation therapy for traumatic portal vein injure guided by contrast-enhanced ultrasonography" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "249" "paginaFinal" => "256" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1227 "Ancho" => 1949 "Tamanyo" => 312703 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">A.</span> Portal vein injuries in the hepatic subsegment. <span class="elsevierStyleBold">B.</span> Contrast-enhanced ultrasonography (CEUS) revealed active bleeding from the injured vessel (arrows). <span class="elsevierStyleBold">C.</span> Three minutes after local injection of hemostatic agent, CEUS shows no evidence of active bleeding, and the treated areas are in flaky irregular shape, or with no perfusion (arrows). <span class="elsevierStyleBold">D.</span> Gross appearance of the liver after cessation of bleeding with local injection of hemostatic agent. Active bleeding stops, and the closure of the injury site is intact (arrows).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Yukun Luo, Qiang Liu, Ziyu Jiao, Rong Wu, Jie Tang, Faqin Lv" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Yukun" "apellidos" => "Luo" ] 1 => array:2 [ "nombre" => "Qiang" "apellidos" => "Liu" ] 2 => array:2 [ "nombre" => "Ziyu" "apellidos" => "Jiao" ] 3 => array:2 [ "nombre" => "Rong" "apellidos" => "Wu" ] 4 => array:2 [ "nombre" => "Jie" "apellidos" => "Tang" ] 5 => array:2 [ "nombre" => "Faqin" "apellidos" => "Lv" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119310312?idApp=UINPBA00004N" "url" => "/16652681/0000001100000002/v1_201906150950/S1665268119310312/v1_201906150950/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "titulo" => "Increased mortality from acute liver failure in Mexico" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "257" "paginaFinal" => "262" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Norberto C. Chávez-Tapia, Tonatiuh Barrientos-Gutiérrez, Carlos Manuel Guerrero-López, Jean Josue Santiago-Hernández, Nahum Méndez-Sánchez, Misael Uribe" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Norberto C." "apellidos" => "Chávez-Tapia" "email" => array:1 [ 0 => "nchavezt@medicasur.org.mx" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "aff1" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor1" ] ] ] 1 => array:3 [ "nombre" => "Tonatiuh" "apellidos" => "Barrientos-Gutiérrez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "**" "identificador" => "aff2" ] 1 => array:2 [ "etiqueta" => "***" "identificador" => "aff3" ] ] ] 2 => array:3 [ "nombre" => "Carlos Manuel" "apellidos" => "Guerrero-López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "***" "identificador" => "aff3" ] ] ] 3 => array:3 [ "nombre" => "Jean Josue" "apellidos" => "Santiago-Hernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "aff1" ] ] ] 4 => array:3 [ "nombre" => "Nahum" "apellidos" => "Méndez-Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "aff1" ] ] ] 5 => array:3 [ "nombre" => "Misael" "apellidos" => "Uribe" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "aff1" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Obesity and Digestive Diseases Unit, Medica Sur Clinic and Foundation, Mexico City, Mexico" "etiqueta" => "*" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "Center for Integrative Approaches to Health Disparities, University of Michigan" "etiqueta" => "**" "identificador" => "aff2" ] 2 => array:3 [ "entidad" => "National Institute of Public Health, Mexico City, Mexico" "etiqueta" => "***" "identificador" => "aff3" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Correspondence and reprint request:" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 756 "Ancho" => 1485 "Tamanyo" => 118487 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Mortality rate from acute liver failure (per 10,000,000 habitants) classified by age.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">Acute liver failure (ALF) is an uncommon but life-threatening liver disease, characterized by the presence of acute liver damage, encephalopathy, coagulopathy and jaundice. ALF can be divided in hyperacute (less than seven days from the onset of encephalopathy), acute (more than eight days, but less than four weeks from the onset of encephalopathy) and subacute (more than four weeks from the onset of encephalopathy).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">The epidemiology of ALF is heterogeneous, being geographic variations and age the most relevant factors in the pattern of disease etiology. This etio-logical variation could affect the prognosis and therapeutic options.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> ALF is considered a rare disease, with an incidence rate of 10-60 cases per 10,000,000 inhabitants in developed countries.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The ALF mortality rate fluctuates depending on its severity and on access to liver transplantation, and ranges from 13 to 33%.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> ALF has a significant impact on liver transplantation programs, accounting for 9-11% of transplants. Liver transplantation significantly reduces ALF mortality, but access to it is still limited.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In developed countries, the consumption of acetaminophen and other drugs has overtaken viral infection as the primary cause of ALF, accounting for at least 50% of cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However, in developing countries, information regarding the epidemiology of ALF is scarce. The aim of this study was to analyze the data for ALF from the nationwide statistics registry of Mexico.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and Methods</span><p id="p0015" class="elsevierStylePara elsevierViewall">The mortality databases were obtained from the National System of Health Information (available at <a href="http://www.sinais.salud.gob.mx/basesdedatos/index.html">http://www.sinais.salud.gob.mx/basesdedatos/index.html</a>; accessed September 2, 2011) for every year from 1998 to 2009. The databases contained all deaths registered in Mexico, coded under the International Classification of Diseases version 10 (ICD-10) for the general cause of death, specific cause of death, place of death, age, sex and other socioeconomic variables. Census data from the National Population Council were used to estimate the Mexican population on July 1 in each year of the period examined, overall and by age groups, sex and region (available at <a href="http://www.conapo.gob.mx">http://www.conapo.gob.mx</a>; accessed July 13, 2011).</p><p id="p0020" class="elsevierStylePara elsevierViewall">The ALF-related deaths were classified into two general types based on the ICD-10 descriptors:</p><p id="p0025" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="li0005"><li class="elsevierStyleListItem" id="list0005"><span class="elsevierStyleLabel">•</span><p id="p0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">B-codes.</span> Including deaths caused by B150 (hepatitis A, with hepatic coma). B160, acute hepatitis B with delta agent, with hepatic coma. B162, acute hepatitis B without delta agent, with hepatic coma; and B190, unspecified viral hepatitis, with hepatic coma; and</p></li><li class="elsevierStyleListItem" id="list0010"><span class="elsevierStyleLabel">•</span><p id="p0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">K-codes.</span> Including deaths caused by K720 (acute and subacute hepatic failure), K760 (fatty change in the liver, not otherwise classified), K762 (central hemorrhagic necrosis of the liver) and K763 (infarction of the liver).</p></li></ul></p><p id="p0040" class="elsevierStylePara elsevierViewall">The mortality rates were calculated as the number of deaths per 10 million inhabitants per year. The calculated mortality rates were regressed over the calendar year using joinpoint regression to test for changes in mortality trends over time. Briefly, joinpoint regression uses an algorithm that tests whether a multisegmented line is a significantly better fit than a straight or less-segmented line, thus identifying break points in the trend, called joinpoints. Each joinpoint denotes a statistically significant (P = 0.05) change in the trend.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In our analysis, a maximum of three joinpoints (four line segments) were allowed for each model. The data were analyzed using PASW® (PASW Statistics Version 18.0.9, 2009; IBM, Chicago, IL, USA) and the Joinpoint Regression Program, Version 3.5.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="p0045" class="elsevierStylePara elsevierViewall">Geographic differences in the ALF mortality rates were assessed using the regional divisions of the country proposed by the National Institute of Statistics, Geography and Informatics, as follows:</p><p id="p0050" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="li0010"><li class="elsevierStyleListItem" id="list0015"><span class="elsevierStyleLabel">•</span><p id="p0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Zone 1.</span> Guerrero, Oaxaca and Chiapas.</p></li><li class="elsevierStyleListItem" id="list0020"><span class="elsevierStyleLabel">•</span><p id="p0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Zone 2.</span> Campeche, Tabasco, Veracruz, Puebla, Hidalgo and San Luis Potosí.</p></li><li class="elsevierStyleListItem" id="list0025"><span class="elsevierStyleLabel">•</span><p id="p0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Zone 3.</span> Michoacán, Guanajuato, Zacatecas, Durango and Tlaxcala.</p></li><li class="elsevierStyleListItem" id="list0030"><span class="elsevierStyleLabel">•</span><p id="p0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Zone 4.</span> Morelos, Estado de México, Querétaro, Nayarit, Colima, Sinaloa, Yucatán and Quintana Roo.</p></li><li class="elsevierStyleListItem" id="list0035"><span class="elsevierStyleLabel">•</span><p id="p0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Zone 5.</span> Tamaulipas, Chihuahua, Sonora, Baja California and Baja California Sur.</p></li><li class="elsevierStyleListItem" id="list0040"><span class="elsevierStyleLabel">•</span><p id="p0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Zone 6.</span> Nuevo León, Coahuila, Jalisco and Aguascalientes; and</p></li><li class="elsevierStyleListItem" id="list0045"><span class="elsevierStyleLabel">•</span><p id="p0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Zone 7.</span> Mexico City.</p></li></ul></p><p id="p0090" class="elsevierStylePara elsevierViewall">A separate linear regression line was fitted for each zone for the 1998-2006 and 2007-2009 periods to identify differences in the slopes of the ALF mortality rates between periods and regions.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="p0095" class="elsevierStylePara elsevierViewall">From 1998 to 2009, 2,193 deaths attributable to ALF were reported. From 1998 to 2006, the number of ALF-related deaths remained stable, averaging 137 deaths per year. After 2006, ALF-related deaths from all causes increased steadily, although viral etiologies showed a steeper increase, accounting for the highest number of deaths in 2009 (<a class="elsevierStyleCrossRef" href="#f0005">Figure 1</a>).</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><p id="p0100" class="elsevierStylePara elsevierViewall">The mortality rates behaved in a similar manner. Deaths classified as K720 showed a twofold increase from 1998 to 2009 (from 9.1 to 18.3 deaths per 10,000,000 inhabitants). Similarly, K760 showed a 2.3-fold increase for the same period (from 1.67 to 3.81 deaths per 10,000,000 inhabitants) (<a class="elsevierStyleCrossRef" href="#f0010">Figure 2</a>). A 10-fold increase in deaths was observed from 1998 to 2009 for the B-code etiologies (from 1.8 to 18.1 deaths per 10,000,000 inhabitants). Overall, ALF-related mortality experienced a threefold increase from 1998 to 2009 (from 13.1 to 40.2 deaths per 10,000,000 habitants). Higher mortality rates, as well as increased rates over time, were concentrated in the group of patients over 45 years old, particularly after 2006 (<a class="elsevierStyleCrossRef" href="#f0015">Figure 3</a>). No differences by sex were observed.</p><elsevierMultimedia ident="f0010"></elsevierMultimedia><elsevierMultimedia ident="f0015"></elsevierMultimedia><p id="p0105" class="elsevierStylePara elsevierViewall">The trends in ALF-related mortality displayed important increases after 2006 (<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>). Joinpoint analysis revealed that across all regions of Mexico, deaths attributable to viral causes (B-codes) showed an average increase of six deaths per year after 2006 compared with previous years (<a class="elsevierStyleCrossRef" href="#f0020">Figure 4</a>); the increases were remarkably high for Mexico City (zone 7). For the K-code deaths, an increase of nine deaths per year was observed after 2007 in zones 1 (Guerrero, Oaxaca and Chiapas) and 6 (Nuevo León, Coahuila, Jalisco and Aguascalientes); the other zones maintained the same slopes over time.</p><elsevierMultimedia ident="t0005"></elsevierMultimedia><elsevierMultimedia ident="f0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="p0110" class="elsevierStylePara elsevierViewall">ALF is a rare but lethal disease with important geographic variations in its etiology and prognosis. To the best of our knowledge, this is the first national analysis of ALF in Latin America. Some reports have previously been published involving pediatric populations.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and infectious etiologies of ALF.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> We analyzed the records of ALF-related mortality in Mexico for 11 years. The most striking finding was the increase in the number of deaths in the last three years of the period. Mortality increased for all etiologies, but hepatitis-related ALF caused by hepatitis A and B viruses and undetermined viruses showed the largest increases.</p><p id="p0115" class="elsevierStylePara elsevierViewall">Because of the secondary and ecological nature of the present study, we are unable to provide a causal explanation for the increase in ALF mortality. However, some considerations can be examined to help interpret these findings. The incidence of hepatitis infections showed its last peak in Mexico in 1997,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and has remained steady since then.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> An increase in hepatitis-related ALF mortality with a stable incidence of hepatitis could suggest an increase in lethality. However, the assessment of lethality in this situation is difficult because no information on the time lag between hepatitis onset and ALF development exists, precluding any meaningful statements about lethality. Therefore, the current cases of ALF could reflect the 10-year lag since the 1997 hepatitis peak well as present concurrent development of hepatitis and ALF.</p><p id="p0120" class="elsevierStylePara elsevierViewall">We relied on national records to assess these trends, which are subject to reporting bias and changes in the probability of disease detection arising from changes in access to health care. The simultaneous increase in all etiologies and across sexes suggests an improvement in the registration of ALF patients, probably resulting from improved access to health care. ALF is an expensive disease, requiring relatively advanced technological resources to establish an etiological diagnosis. Mexico has recently undergone an extensive reform in health-care access through Seguro Popular, a subsidized governmental system created to provide access to health care for the previously uninsured population. From 2004 to June 2011, 48.5 million people became affiliated with Seguro Popular, many of whom belong to vulnerable groups (Informe de resultados 2011, available at: <a href="http://www.seguro-popular.gob.mx//images/contenidos/Informes_Resultados/informe_resultados_1sem_2011.pdf">http://www.seguro-popular.gob.mx//images/contenidos/Informes_Resultados/informe_resultados_1sem_2011.pdf</a>). Because Seguro Popular provides coverage for catastrophic expenses and facilitates access to health care, it is reasonable to expect that previously untreated cases of ALF will now be properly diagnosed and followed up. This could explain the increase in ALF mortality, particularly among the elderly.</p><p id="p0125" class="elsevierStylePara elsevierViewall">Another likely explanation is an increase in the vulnerability of the population infected with hepatitis. It is well known that many populations with a formerly high prevalence of hepatitis A viral infections are moving toward medium prevalence in response to improved sanitation. At the same time, hepatitis infections in adulthood have increased as a result of intravenous drug use and sexual transmission, which are also important risk factors for HIV infection, which is still increasing in Mexico.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Recently, some reports have shown that a large proportion of the adult population infected with hepatitis is also infected with HIV. The comorbidity of HIV and hepatitis has been linked to worse health outcomes, including mortality.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Finally, local conditions, such as the rare but still prevalent practice of paying plasma donors, could also contribute to the increase in ALF.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="p0130" class="elsevierStylePara elsevierViewall">It is important to note that there are sociogeographic variations in the main causes of ALF. This joint analysis showed slight temporal and geographic variations. Probably the most relevant is the general increase in B-code disease, but the increase in K-code disease in only zones 1 and 6 is also remarkable. This should encourage local researchers to identify the regional epidemiological characteristics and to develop preventive and therapeutic strategies.</p><p id="p0135" class="elsevierStylePara elsevierViewall">Regardless of the specific causes of the increase, 1,121 ALF-related deaths occurred from 2006 to 2009. During the same period, only 383 patients underwent orthotopic liver transplantation for all causes (available at <a href="http://www.cenatra.salud.gob.mx/interior/trasplante_estadisticas.html">http://www.cenatra.salud.gob.mx/interior/trasplante_estadisticas.html</a>; accessed October 1, 2011). This mismatch highlights the dramatic shortage of organs required to accommodate at least the patients who most urgently require liver transplantation. In the current scenario, the vast majority of patients affected by ALF will succumb to the ominous natural history of the disease. This should encourage the development of alternative stratagems to promote living-donor liver transplantation,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> to improve the management of these patients in critical care units, and to promote research into prognos-tic<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and therapeutic options.</p><p id="p0140" class="elsevierStylePara elsevierViewall">This study was based on administrative data, and some limitations are intrinsic to this methodology. Moreover, other causes of acute liver failure were not included (e.g., acetaminophen, autoimmune disease, <span class="elsevierStyleItalic">Amanita phalloides</span> consumption).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusion</span><p id="p0145" class="elsevierStylePara elsevierViewall">In conclusion, in this study, we have shown an increase in the mortality attributable to ALF in Mexico, which was greater in people older than 45 years, with slight geographic variations. These findings warrant further research to determine the real cause of this increase in ALF-related mortality.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Abbreviations</span><p id="p0150" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="li0015"><li class="elsevierStyleListItem" id="list0050"><span class="elsevierStyleLabel">•</span><p id="p0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">ALF:</span> Acute liver failure.</p></li><li class="elsevierStyleListItem" id="list0055"><span class="elsevierStyleLabel">•</span><p id="p0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">ICD-10:</span> International Classification of Diseases version 10.</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Financial Support</span><p id="p0165" class="elsevierStylePara elsevierViewall">Partially supported by Medica Sur Clinic & Foundation.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1207307" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abs0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1124353" "titulo" => "Key words" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Abbreviations" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Financial Support" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Key words" "identificador" => "xpalclavsec1124353" "palabras" => array:3 [ 0 => "Fulminant liver failure" 1 => "Hepatitis" 2 => "Epidemiology" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abs0005" class="elsevierStyleSection elsevierViewall"><p id="sp0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Introduction.</span> There is significant geographic variation in the etiology and prognosis of acute liver failure (ALF). Since, little information is available for Latin America. We analyzed ALF mortality trends in Mexico.</p><p id="sp1025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Material and methods.</span> The rates of mortality attributable to ALF were obtained for 1998 to 2009 from the National System of Health Information in Mexico and analyzed according to date, etiology, sex, age and geographic characteristics through graphical assessment and joinpoint regression.</p><p id="sp8030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Results.</span> From 1998 to 2009, 2,193 ALF-related deaths were reported. A threefold increase in ALF mortality was observed during the period from 1998 to 2009 (the global mortality rate increased from 13.1 to 40.2 deaths per 10,000,000 inhabitants). The most significant increase was observed for viral etiologies after 2006, affecting people 45 years old and over.</p><p id="sp9030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Conclusion.</span> ALF-related deaths have increased since 2006. Although we cannot speculate on the specific causes of this increase, it may reflect improvements in the access of vulnerable populations to health care.</p></span>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 773 "Ancho" => 1451 "Tamanyo" => 110662 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Total deaths attributable to acute liver failure in the 1998-2009 period according to the national registry in Mexico.</p>" ] ] 1 => array:7 [ "identificador" => "f0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 724 "Ancho" => 1478 "Tamanyo" => 90495 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Mortality rate from acute liver failure (per 10,000,000 habitants) according to the ICD etiology groups.</p>" ] ] 2 => array:7 [ "identificador" => "f0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 756 "Ancho" => 1485 "Tamanyo" => 118487 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Mortality rate from acute liver failure (per 10,000,000 habitants) classified by age.</p>" ] ] 3 => array:7 [ "identificador" => "f0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2189 "Ancho" => 1738 "Tamanyo" => 275899 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">Mortality rate from acute liver failure (per 10,000,000 habitants) and trends using joinpoint analysis.</p>" ] ] 4 => array:7 [ "identificador" => "t0005" "etiqueta" => "<span class="elsevierStyleBold">Table 1</span>" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="npara0005" class="elsevierStyleSimplePara elsevierViewall">ND: not detected.</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 " colspan="5" align="center" valign="middle" scope="col" style="border-bottom: 2px solid black">B-codes</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="5" align="center" valign="middle" scope="col" style="border-bottom: 2px solid black">K-codes</th></tr><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"> \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 " colspan="2" align="center" valign="middle" scope="col">Slope</th><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"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \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 " colspan="3" align="center" valign="middle" scope="col">Slope</th><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"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">Zone \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="center" valign="middle" scope="col">First segment \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="center" valign="middle" scope="col">Second segment \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="center" valign="middle" scope="col">Δ \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="center" valign="middle" scope="col">Joinpoint \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="center" valign="middle" scope="col">First segment \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \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="center" valign="middle" scope="col">Second segment \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="center" valign="middle" scope="col">Δ \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="center" valign="middle" scope="col">Joinpoint \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" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">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="center" valign="middle">0.0 \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="center" valign="middle">5.7 \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="center" valign="middle">5.7 \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="center" valign="middle">2005 \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="center" valign="middle">−0.14 \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="" 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="center" valign="middle">9.64 \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="center" valign="middle">9.8 \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="center" valign="middle">2007 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">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="center" valign="middle">0.0 \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="center" valign="middle">6.8 \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="center" valign="middle">6.8 \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="center" valign="middle">2006 \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="" 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="center" valign="middle">0.5 \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="" 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="center" valign="middle">- \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="center" valign="middle">ND \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">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="center" valign="middle">0.0 \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="center" valign="middle">2.4 \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="center" valign="middle">2.4 \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="center" valign="middle">2006<a class="elsevierStyleCrossRef" href="#fn0005">*</a> \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="" 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="center" valign="middle">0.5 \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="" 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="center" valign="middle">- \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="center" valign="middle">ND \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">4 \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="center" valign="middle">−0.1 \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="center" valign="middle">4.3 \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="center" valign="middle">4.5 \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="center" valign="middle">2006 \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="" 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="center" valign="middle">0.3 \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="" 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="center" valign="middle">- \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="center" valign="middle">ND \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">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="center" valign="middle">−0.2 \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="center" valign="middle">3.4 \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="center" valign="middle">3.6 \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="center" valign="middle">2006 \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="" 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="center" valign="middle">0.5 \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="" 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="center" valign="middle">- \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="center" valign="middle">ND \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">6 \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="center" valign="middle">−0.1 \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="center" valign="middle">3.6 \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="center" valign="middle">3.6 \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="center" valign="middle">2006 \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="center" valign="middle">−0.1 \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="" 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="center" valign="middle">8.8 \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="center" valign="middle">8.8 \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="center" valign="middle">2007 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">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="center" valign="middle">−0.6 \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="center" valign="middle">15.4 \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="center" valign="middle">16.0 \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="center" valign="middle">2006 \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="" 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="center" valign="middle">2.1 \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="" 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="center" valign="middle">- \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="center" valign="middle">ND \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2060772.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "fn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="np00005">Second and third segments presented. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 0 | 1 |
| 2024 October | 15 | 12 | 27 |
| 2024 September | 28 | 16 | 44 |
| 2024 August | 19 | 11 | 30 |
| 2024 July | 20 | 10 | 30 |
| 2024 June | 21 | 10 | 31 |
| 2024 May | 22 | 7 | 29 |
| 2024 April | 29 | 4 | 33 |
| 2024 March | 17 | 1 | 18 |
| 2024 February | 10 | 5 | 15 |
| 2024 January | 9 | 5 | 14 |
| 2023 December | 23 | 8 | 31 |
| 2023 November | 19 | 12 | 31 |
| 2023 October | 11 | 6 | 17 |
| 2023 September | 18 | 2 | 20 |
| 2023 August | 34 | 10 | 44 |
| 2023 July | 13 | 21 | 34 |
| 2023 June | 29 | 5 | 34 |
| 2023 May | 52 | 3 | 55 |
| 2023 April | 31 | 1 | 32 |
| 2023 March | 38 | 5 | 43 |
| 2023 February | 36 | 3 | 39 |
| 2023 January | 36 | 2 | 38 |
| 2022 December | 19 | 7 | 26 |
| 2022 November | 36 | 4 | 40 |
| 2022 October | 21 | 6 | 27 |
| 2022 September | 26 | 3 | 29 |
| 2022 August | 18 | 6 | 24 |
| 2022 July | 12 | 6 | 18 |
| 2022 June | 16 | 11 | 27 |
| 2022 May | 23 | 8 | 31 |
| 2022 April | 12 | 11 | 23 |
| 2022 March | 27 | 14 | 41 |
| 2022 February | 22 | 5 | 27 |
| 2022 January | 33 | 5 | 38 |
| 2021 December | 19 | 17 | 36 |
| 2021 November | 33 | 4 | 37 |
| 2021 October | 45 | 15 | 60 |
| 2021 September | 30 | 5 | 35 |
| 2021 August | 5 | 6 | 11 |
| 2021 July | 9 | 7 | 16 |
| 2021 June | 6 | 8 | 14 |
| 2021 May | 14 | 9 | 23 |
| 2021 April | 25 | 13 | 38 |
| 2021 March | 8 | 3 | 11 |
| 2021 February | 6 | 6 | 12 |
| 2021 January | 7 | 9 | 16 |
| 2020 December | 6 | 7 | 13 |
| 2020 November | 4 | 6 | 10 |
| 2020 October | 8 | 5 | 13 |
| 2020 September | 9 | 5 | 14 |
| 2020 August | 7 | 4 | 11 |
| 2020 July | 5 | 2 | 7 |
| 2020 June | 3 | 2 | 5 |
| 2020 May | 3 | 5 | 8 |
| 2020 March | 6 | 1 | 7 |
| 2020 February | 4 | 1 | 5 |
| 2020 January | 8 | 15 | 23 |
| 2019 December | 3 | 6 | 9 |
| 2019 November | 3 | 1 | 4 |
| 2019 October | 2 | 2 | 4 |
| 2019 September | 3 | 3 | 6 |
| 2019 August | 1 | 1 | 2 |
| 2019 July | 0 | 5 | 5 |
| 2019 June | 2 | 7 | 9 |
Show all
