metricas
covid
Buscar en
Annals of Hepatology
Toda la web
Inicio Annals of Hepatology The safety and feasibility of large volume paracentesis performed by an experien...
Journal Information

Statistics

Follow this link to access the full text of the article

The safety and feasibility of large volume paracentesis performed by an experienced nurse practitioner
Nooman Gilani
,
Corresponding author
ngilani@pol.net
ngilani@hotmail.com

Correpondence and reprint request:
, Nayan Patel*, Richard D Gerkin*, Francisco C Ramirez*, Erin E Tharalson*, Kandarp Patel*
* Department of Gastroenterology and Hepatology, Carl. T. Hayden VA Medical Center, Phoenix, Arizona, USA 85012
Read
3353
Times
was read the article
418
Total PDF
2935
Total HTML
Share statistics
 array:24 [
  "pii" => "S1665268119317508"
  "issn" => "16652681"
  "doi" => "10.1016/S1665-2681(19)31750-8"
  "estado" => "S300"
  "fechaPublicacion" => "2009-10-01"
  "aid" => "71412"
  "copyright" => "Fundación Clínica Médica Sur, A.C."
  "copyrightAnyo" => "2009"
  "documento" => "article"
  "crossmark" => 0
  "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
  "subdocumento" => "fla"
  "cita" => "Ann Hepatol. 2009;8:359-63"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 178
    "formatos" => array:3 [
      "EPUB" => 9
      "HTML" => 140
      "PDF" => 29
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S166526811931751X"
    "issn" => "16652681"
    "doi" => "10.1016/S1665-2681(19)31751-X"
    "estado" => "S300"
    "fechaPublicacion" => "2009-10-01"
    "aid" => "71413"
    "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. 2009;8:364-70"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 61
      "formatos" => array:3 [
        "EPUB" => 12
        "HTML" => 28
        "PDF" => 21
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "titulo" => "Hepatoprotective effect of pentoxifylline against D-galactosamine-induced hepatotoxicity in rats"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "364"
          "paginaFinal" => "370"
        ]
      ]
      "contieneResumen" => array:1 [
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "f0015"
          "etiqueta" => "<span class="elsevierStyleBold"><span class="elsevierStyleItalic">Figure 3</span></span>"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr3.jpeg"
              "Alto" => 744
              "Ancho" => 2077
              "Tamanyo" => 226078
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Effect of D-Gal on hepatic lipid peroxidation and total nitrites in normal rats and those pretreated with PTX&#44; SYM and their combination&#46; <span class="elsevierStyleBold">A&#46;</span> Effect of D-Gal on the hepatic lipid peroxidation in normal rats pretreated with either PTX or SYM or their combination&#46; <span class="elsevierStyleBold">B&#46;</span> Effect of D-Gal on the hepatic total nitrites in normal rats pretreated with PTX and SYM individually or in concurrent administration&#46; Values of each bar represent the mean &#177; SEM of 7 observations&#46; <span class="elsevierStyleBold">&#42;</span> Statistically significant from the control group at the significance level p &#60; 0&#46;05&#46; &#35;&#44; f&#44; &#948; Statistically significant of PTX&#44; SYM and &#40;PTX and SYM&#41; versus D-Gal-treated group&#44; respectively&#44; at the significance level p &#60; 0&#46;05&#46; <span class="elsevierStyleBold">MDA&#58;</span> Malondialdhyde and other symbols as in <a class="elsevierStyleCrossRef" href="#f0005"><span class="elsevierStyleItalic">Figure 1</span></a>&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Ashraf Taye, Mohamed A&#46; El-Moselhy, Magdy K&#46;A&#46; Hassan, Hanaa M&#46; Ibrahim, Aliaa F&#46; Mohammed"
          "autores" => array:5 [
            0 => array:2 [
              "nombre" => "Ashraf"
              "apellidos" => "Taye"
            ]
            1 => array:2 [
              "nombre" => "Mohamed A&#46;"
              "apellidos" => "El-Moselhy"
            ]
            2 => array:2 [
              "nombre" => "Magdy K&#46;A&#46;"
              "apellidos" => "Hassan"
            ]
            3 => array:2 [
              "nombre" => "Hanaa M&#46;"
              "apellidos" => "Ibrahim"
            ]
            4 => array:2 [
              "nombre" => "Aliaa F&#46;"
              "apellidos" => "Mohammed"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S166526811931751X?idApp=UINPBA00004N"
    "url" => "/16652681/0000000800000004/v1_201907070733/S166526811931751X/v1_201907070733/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S1665268119317491"
    "issn" => "16652681"
    "doi" => "10.1016/S1665-2681(19)31749-1"
    "estado" => "S300"
    "fechaPublicacion" => "2009-10-01"
    "aid" => "71411"
    "copyright" => "Fundaci&#243;n Cl&#237;nica M&#233;dica Sur&#44; A&#46;C&#46;"
    "documento" => "article"
    "crossmark" => 0
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "fla"
    "cita" => "Ann Hepatol. 2009;8:353-8"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 182
      "formatos" => array:3 [
        "EPUB" => 17
        "HTML" => 120
        "PDF" => 45
      ]
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "titulo" => "Early treatment with N-acetylcysteine in children with acute liver failure secondary to hepatitis A"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "353"
          "paginaFinal" => "358"
        ]
      ]
      "contieneResumen" => array:1 [
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Norberto Sotelo, Mar&#237;a de los &#193;ngeles Durazo, Alejandro Gonzalez, Nagasharmila Dhanakotti"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Norberto"
              "apellidos" => "Sotelo"
            ]
            1 => array:2 [
              "nombre" => "Mar&#237;a"
              "apellidos" => "de los &#193;ngeles Durazo"
            ]
            2 => array:2 [
              "nombre" => "Alejandro"
              "apellidos" => "Gonzalez"
            ]
            3 => array:2 [
              "nombre" => "Nagasharmila"
              "apellidos" => "Dhanakotti"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119317491?idApp=UINPBA00004N"
    "url" => "/16652681/0000000800000004/v1_201907070733/S1665268119317491/v1_201907070733/en/main.assets"
  ]
  "en" => array:16 [
    "idiomaDefecto" => true
    "titulo" => "The safety and feasibility of large volume paracentesis performed by an experienced nurse practitioner"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "359"
        "paginaFinal" => "363"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Nooman Gilani, Nayan Patel, Richard D Gerkin, Francisco C Ramirez, Erin E Tharalson, Kandarp Patel"
        "autores" => array:6 [
          0 => array:4 [
            "nombre" => "Nooman"
            "apellidos" => "Gilani"
            "email" => array:2 [
              0 => "ngilani@pol.net"
              1 => "ngilani@hotmail.com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor1"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Nayan"
            "apellidos" => "Patel"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Richard D"
            "apellidos" => "Gerkin"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Francisco C"
            "apellidos" => "Ramirez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Erin E"
            "apellidos" => "Tharalson"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "Kandarp"
            "apellidos" => "Patel"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:3 [
            "entidad" => "Department of Gastroenterology and Hepatology&#44; Carl&#46; T&#46; Hayden VA Medical Center&#44; Phoenix&#44; Arizona&#44; USA 85012"
            "etiqueta" => "&#42;"
            "identificador" => "aff1"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor1"
            "etiqueta" => "&#42;"
            "correspondencia" => "Correpondence and reprint request&#58;"
          ]
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Background</span><p id="p0005" class="elsevierStylePara elsevierViewall">Recently released final data for U&#46;S&#46; deaths in 2006 from the National Vital Statistics Reports classifies cirrhosis as the 12<span class="elsevierStyleSup">th</span> leading cause of death&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Patients with cirrhosis are also at risk for substantial morbidity&#46; As portal hypertension worsens&#44; patients with cirrhosis may develop complications including ascites&#44; hepatic encephalopathy&#44; and variceal hemorrhage&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> First line therapy for ascites includes dietary sodium restriction and diuretics&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> At times&#44; patients may require large volume paracentesis &#40;LVP&#41; for treatment of tense ascites causing abdominal pain&#44; early satiety&#44; nausea&#44; vomiting&#44; or respiratory compromise&#46; LVP may be required on as needed basis for some patients because of sodium non-adherence&#44; or sub-optimal diuresis&#46; However&#44; a subset of patients with refractory ascites or diuretic intolerance will require LVP more frequently&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> LVP in the outpatient setting is often time consuming and being performed by fewer physicians&#46; Thus&#44; patients will visit the emergency department or get admitted to the hospital for LVP resulting in increased use of resources and health care spending&#46;</p><p id="p0010" class="elsevierStylePara elsevierViewall">Nurse practitioners &#40;NPs&#41; may provide a solution to this dilemma&#46; NPs have undergone graduate level training to work and make independent diagnostic and treatment decisions regarding patient care&#46; The role of NPs in the field of gastroenterology&#44; particularly in performing flexible sigmoidoscopy has previously been described both in the United States&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and in the United Kingdom&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7</span></a>-<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> At our institution&#44; after initial supervision&#44; a certified NP has independently performed LVP in a dedicated cirrhosis clinic&#46; The purpose of our study was to evaluate the feasibility and safety of LVP performed by a NP trained to perform paracentesis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="p0015" class="elsevierStylePara elsevierViewall">A retrospective analysis of patients undergoing an outpatient LVP at our institution was performed between January 2003 and May 2007&#46; Procedure details had previously been entered in an electronic database in a prospective manner on the day of procedure&#46; Baseline information included age&#44; gender&#44; race&#44; etiology of cirrhosis&#44; and biochemical profile performed at a date closest to LVP to calculate the Childs Pugh Class and MELD score&#46; Information on the practitioner performing LVP &#40;physician or NP&#41;&#44; number of attempts&#44; and volume of ascites removed were recorded&#46; Complications including post paracentesis hypotension&#44; bleeding&#44; local leakage of ascitic fluid&#44; local site infection&#44; secondary bacterial peritonitis&#44; perforation&#44; and death were compared between the two groups&#46; Post paracentesis hypotension was defined as a decrease in systolic blood pressure &#8805; 20 mmHg after paracentesis&#46; In the two groups analyzed&#44; paracentesis was performed either by a single gastroenterology &#40;GI&#41; NP&#44; or by a first or second year GI fellow&#46; The GI NP completed 10 supervised paracentesis prior to performing them independently&#46; The gastroenterology fellows&#44; who had previously completed 3 years of internal medicine training&#44; had prior experience in large volume paracentesis in their respective residency programs&#46; The project was approved by the local IRB&#46;</p><p id="p0020" class="elsevierStylePara elsevierViewall">Informed consent was obtained prior to each paracentesis&#46; The Safe-T Centesis 6 Fr Catheter Drainage Tray &#40;Cardinal Health Inc&#46;&#44; Dublin&#44; OH&#41; was the kit routinely used for procedures&#46; A standard technique for paracentesis was used&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Patients were positioned comfortably in the supine position with the head of bed elevated to 20-30 degrees&#46; Ultrasound guidance was not used either by the NP or the fellows&#46; Physical examination was used to choose either a right lower quadrant &#40;RLQ&#41; or left lower quadrant &#40;LLQ&#41; site&#46; The abdominal wall was percussed to determine the level of dullness&#46; An optimal site 2 to 4 cm medial and cephalad to the anterior superior iliac spine in the RLQ or LLQ was always chosen&#46; Care was taken to avoid far lateral sites&#44; areas of superficial infection or previous scarring&#44; and engorged veins&#46; Universal precautions with regard to handling of needles and body fluids was observed&#46; A clean gown and sterile gloves was always used&#46; The skin around the site selected for puncture was prepared with 3 povidone iodine swab sticks&#46; The fenestrated drape accompanying the kit was used to form a sterile field&#46; Local anesthetic in the form of 1&#37; lidocaine hydrochloride USP was drawn up into a 10 mL syringe and administered subcutaneously using a 25-G x 1 &#189;&#8221; needle to form a wheal&#46; The wheal site was punctured with a 22-G x 1 &#189;&#8221; needle&#44; injecting and aspirating while advancing the needle deeper into the soft tissue&#46; Upon entering the peritoneal cavity&#44; and aspirating ascites&#44; injection of lidocaine was discontinued&#46; A small stab wound was made with the scalpel provided in the kit&#46; The 6 Fr 20 cm Safe-T Centesis catheter with multiple side holes&#44; over a metal introducer needle&#44; was then inserted in the same tract until ascitic fluid was aspirated&#46; The introducer needle was removed leaving the catheter &#40;pig tail shape&#41; in the peritoneal cavity&#46; The drainage tubing with needle was connected for attachment to 1 liter vacuum bottles&#46; After the desired amount of fluid was obtained&#44; the catheter was removed&#44; and pressure was applied to the puncture site for a short period prior to application of a bandage&#46; Intravenous albumin 25&#37; solution at 8 g&#47;L was replaced for ascites greater than or equal to 5 L removed&#46;</p><p id="p0025" class="elsevierStylePara elsevierViewall">All patients were followed in both the NP continuity clinic and physician &#40;GI fellow or attending&#41; continuity clinic&#46; All GI fellow clinics are staffed by an attending GI physician&#46; The typical paradigm is that patients are followed more frequently in the NP clinic with follow-up every one to two months&#44; while being seen in the physician clinic every three to four months&#46; Details of the visit and changes in treatment plan by the NP are always sent to the physician through electronic medical records&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="p0030" class="elsevierStylePara elsevierViewall">A total of 489 procedures &#40;245 by NP and 244 by physicians&#41; were recorded in 84 patients&#46; Baseline characteristics of patients undergoing LVP were similar in both groups including age&#44; gender&#44; etiology of liver disease&#44; Childs Pugh Class&#44; and MELD Score &#40;<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>&#41;&#46; In terms of complications&#44; there was no statistical difference whether LVP was performed by the NP or by a physician &#40;<a class="elsevierStyleCrossRef" href="#t0010">Table 2</a>&#41;&#46; Five procedures were complicated with bleeding in LVP performed by physicians &#40;2 localized hematomas&#44; and 3 with hemoperitoneum requiring blood transfusion&#41; compared to three procedures &#40;2 local hematoma&#44; 1 hemoperitoneum requiring blood transfusion&#41; in the NP group&#46; Three procedures in the physician group were complicated by infection &#40;2 secondary bacterial peritonitis&#44; 1 local site infection&#41; compared with two &#40;1 secondary bacterial peritonitis&#44; 1 local site infection&#41; in the NP group&#46; There were no deaths&#44; and rates of post paracentesis hypotension&#44; leakage at the site&#44; bleeding&#44; and infections were not statistically different&#46;</p><elsevierMultimedia ident="t0005"></elsevierMultimedia><elsevierMultimedia ident="t0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="p0035" class="elsevierStylePara elsevierViewall">Paracentesis performed by an experienced NP when compared to physicians showed no significant difference in volume of fluid removed per procedure&#44; number of needle attempts&#44; or complications&#46; To date&#44; there is not literature available analyzing the role of NPs in performing paracentesis&#46; A study from Mayo Clinic&#44; Rochester&#44; MN<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> showed that gastrointestinal endoscopy assistants can safely perform paracentesis with adequate training&#46; They recommend an optimal number of 10 supervised procedures for an operator to learn paracentesis&#46; Authors concluded that ultrasound is rarely required&#44; routine correction of coagulopathy and thrombocytopenia is not required&#44; and that there is a significant saving in physician time without any increased patient risk&#46;</p><p id="p0040" class="elsevierStylePara elsevierViewall">When performing any procedure&#44; the diagnostic accuracy and safety must be considered&#46; The role of NPs in performing flexible sigmoidoscopy has been extensively studied&#44; including accuracy and safety&#46; In a study from the UK&#44; Goodfellow&#44; <span class="elsevierStyleItalic">et al</span>&#46; showed that an experienced NP&#44; trained in flexible sigmoidoscopy had a 99&#37; procedure completion rate&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Training before performing independent procedures is of paramount importance&#46; This NP initially had observed 35 procedures&#44; then had withdrawn the endoscope in next 35&#44; and finally performed 35 supervised procedures before performing them independently&#46; Similarly&#44; in a study assessing accuracy of polyp detection&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> the three nurse endoscopists involved in the study completed 100 supervised flexible sigmoidoscopies in a standard training program&#46; In this study&#44; there was no difference found in detection of adenomatous polyps or frequency of complications&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">In an already financially scrutinized healthcare system&#44; the use of NPs may also be cost effective&#46; Wallace&#44; <span class="elsevierStyleItalic">et al</span>&#46; showed that the cost per flexible sigmoidoscopy&#44; including the training cost&#44; was lower for NPs compared to physicians&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Another study by Niv&#44; <span class="elsevierStyleItalic">et al</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> in which an experienced gastroenterology nurse reviewed capsule endoscopy and thumbnailed abnormalities for the physician to review&#44; also showed a savings in cost per examination&#46; In this study&#44; the accuracy of detecting abnormalities was also high with 96&#46;9&#37; interobserver agreement for lesions categorized as &#8220;significant&#8221; by the physician&#46; In the cost analysis&#44; a potential savings of 57&#37; of the cost of examination was calculated&#44; mainly from less time the physician spends reading the study&#46; Additionally&#44; studies of NPs working in primary care<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and performing hysteroscopy<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> show high levels of patient satisfaction for the care they are receiving&#46;</p><p id="p0050" class="elsevierStylePara elsevierViewall">Paracentesis is a procedure in the armamentarium of physicians trained in internal medicine&#46; As patients with cirrhosis decompensate&#44; they may need more frequent LVP to alleviate symptoms&#46; Patients needing paracentesis however may have a difficult time finding a provider to perform this procedure&#44; and are often admitted to the hospital for this routine procedure&#46; Time constraints in outpatient medicine make it difficult for physicians to find a substantial amount of time to perform paracentesis&#46;</p><p id="p0055" class="elsevierStylePara elsevierViewall">Complications in our study are comparable to the reported literature with similar rates of bleeding&#44; leakage&#44; and peritonitis&#46; Significant bleeding after paracentesis in prior studies&#44; defined as either requiring blood transfusion&#44; or a hemoglobin decrease greater than 2 g&#47;dL&#44; was between 0&#37; and 2&#46;7&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Abdominal wall hematoma requiring transfusion was 0&#46;9&#37;&#44; and hematoma not requiring transfusion was also 0&#46;9&#37; in a study by Runyon&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The incidence of ascitic fluid leakage after paracentesis is between 0&#46;36&#37; and 2&#46;35&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and in one study&#44; peritonitis or abscess complicating paracentesis was 0&#46;83&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="p0060" class="elsevierStylePara elsevierViewall">We have a dedicated cirrhosis clinic managed by a NP experienced in both liver disease and paracentesis&#46; After initial training and supervision of paracentesis&#44; our NP has performed more than 200 independent procedures&#44; most without complications&#46; Our study shows no difference between physician and NP performance of LVP&#46; Both groups had a similar volume of ascitic fluid removed&#44; and number of needle attempts&#46; Additionally&#44; complications observed were similar among paracentesis performed by NP and physician&#46; We found that LVP performed by a trained NP is feasible and has an acceptable rate of complications&#46; Studies of patient satisfaction and the cost-effectiveness of this model need to be further evaluated&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Abbreviations</span><p id="p0065" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="li0005"><li class="elsevierStyleListItem" id="list0005"><span class="elsevierStyleLabel">&#8226;</span><p id="p0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">NP&#58;</span> Nurse Practitioner</p></li><li class="elsevierStyleListItem" id="list0010"><span class="elsevierStyleLabel">&#8226;</span><p id="p0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">LVP&#58;</span> Large volume paracentesis</p></li><li class="elsevierStyleListItem" id="list0015"><span class="elsevierStyleLabel">&#8226;</span><p id="p0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">SBP&#58;</span> Spontaneous bacterial peritonitis</p></li></ul></p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Financial disclosure and funding&#58;</span><p id="p0085" class="elsevierStylePara elsevierViewall">None</p></span></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:8 [
        0 => array:3 [
          "identificador" => "xres1217516"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abs0010"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1132897"
          "titulo" => "Key words"
        ]
        2 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Background"
        ]
        3 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Methods"
        ]
        4 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Results"
        ]
        5 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Discussion"
        ]
        6 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Abbreviations"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Financial disclosure and funding&#58;"
            ]
          ]
        ]
        7 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2009-09-17"
    "fechaAceptado" => "2009-11-06"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Key words"
          "identificador" => "xpalclavsec1132897"
          "palabras" => array:4 [
            0 => "Paracentesis"
            1 => "Ascites"
            2 => "Cirrhosis"
            3 => "Nurse practitioner&#8217;s role"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Due to time constraints&#44; fewer physicians are performing large volume paracentesis &#40;LVP&#41; resulting in a longer wait time and more emergency department &#40;ED&#41; and hospital admissions&#46; At our institution&#44; after initial supervision&#44; a certified nurse practitioner &#40;NP&#41; has independently performed LVP in a dedicated cirrhosis clinic&#46; The purpose of our study was to evaluate the feasibility and safety of LVP performed by a NP&#46; A retrospective review of patients undergoing LVP between January 2003 and May 2007 was performed&#46; Baseline patient information and the practitioner performing LVP &#40;physician or NP&#41; were recorded&#46; Complications including post paracentesis hypotension&#44; bleeding&#44; local leakage of ascitic fluid&#44; infection&#44; perforation&#44; and death were compared between the two groups&#46; A total of 245 procedures in 41 patients were performed by a single NP&#44; and 244 in 43 patients by physicians&#46; Baseline characteristics of patients undergoing LVP were similar in two groups&#46; Alcohol was the most common etiology of cirrhosis &#40;46&#37; in NP and 51&#37; in physician group&#41; followed by a combination of alcohol plus HCV &#40;37&#37; in NP and 28&#37; in physician group&#41;&#46; There was similar distribution of Childs class B and C patients in the two groups&#44; as well as average MELD score&#46; Total volume of ascites removed&#44; number of needle attempts&#44; and complications including post paracentesis hypotension&#44; local leakage of ascitic fluid&#44; bleeding&#44; infection&#44; and death were not statistically different between the two groups&#46; Our study shows no difference between physician and NP performance of LVP and complication rates&#46; LVP performed by a NP is feasible and has acceptable rate of complications&#46;</p></span>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "t0005"
        "etiqueta" => "<span class="elsevierStyleBold">Table 1&#46;</span>"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "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="middle" scope="col">Characteristics&nbsp;\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">Nurse Practitioner&nbsp;\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">Physician&nbsp;\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">P value&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Number of patients</span>&nbsp;\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">41&nbsp;\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">43&nbsp;\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">NS&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Age in years &#40;range&#41;</span>&nbsp;\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">66 &#40;44-82&#41;&nbsp;\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">60 &#40;44-81&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Gender &#40;M&#47;F&#41;</span>&nbsp;\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">41&#47;0&nbsp;\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">43&#47;0&nbsp;\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">NS&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Etiology of liver disease</span>&nbsp;\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">&nbsp;\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">&nbsp;\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">&nbsp;\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="left" valign="middle">Hepatitis C&nbsp;\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 &#40;10&#37;&#41;&nbsp;\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 &#40;9&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle">Alcohol&nbsp;\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">19 &#40;46&#37;&#41;&nbsp;\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">22 &#40;51&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle">Hepatitis C and alcohol&nbsp;\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 &#40;37&#37;&#41;&nbsp;\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">12 &#40;28&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle">Hepatitis B&nbsp;\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 &#40;5&#37;&#41;&nbsp;\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">1 &#40;2&#46;5&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle">Cryptogenic&nbsp;\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&nbsp;\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 &#40;7&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle">Hemochromatosis&nbsp;\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">1 &#40;2&#37;&#41;&nbsp;\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">1 &#40;2&#46;5&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Childs Pugh Class</span>&nbsp;\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">&nbsp;\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">&nbsp;\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">&nbsp;\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="left" valign="middle">B&nbsp;\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 &#40;12&#37;&#41;&nbsp;\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 &#40;14&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle">C&nbsp;\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">36 &#40;88&#37;&#41;&nbsp;\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">37 &#40;86&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Mean MELD Score</span>&nbsp;\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&nbsp;\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&nbsp;\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">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2078564.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of patients undergoing LVP&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "t0010"
        "etiqueta" => "<span class="elsevierStyleBold">Table 2&#46;</span>"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "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="middle" scope="col">Values measured&nbsp;\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">Nurse Practitioner&nbsp;\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">Physician&nbsp;\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">P Value&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Number of paracentesis</span>&nbsp;\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">245&nbsp;\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">244&nbsp;\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">NS&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Volume of ascites removed &#40;cc&#41;</span>&nbsp;\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">7796&nbsp;\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">7004&nbsp;\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">NS&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Number of needle attempts</span>&nbsp;\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">1&#46;06&nbsp;\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">1&#46;14&nbsp;\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">NS&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Complications</span>&nbsp;\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 &#40;6&#46;1&#37;&#41;&nbsp;\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 &#40;6&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle">Post Paracentesis Hypotension&nbsp;\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 &#40;4&#37;&#41;&nbsp;\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 &#40;1&#46;2&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle">Leakage at site&nbsp;\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 &#40;1&#46;6&#37;&#41;&nbsp;\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 &#40;1&#46;6&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Bleeding</span>&nbsp;\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">&nbsp;\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">&nbsp;\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">&nbsp;\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="left" valign="middle">Abdominal wall hematoma&nbsp;\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 &#40;0&#46;82&#37;&#41;&nbsp;\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 &#40;0&#46;82&#37;&#41;&nbsp;\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">&nbsp;\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="left" valign="middle">Hemoperitoneum&nbsp;\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">1 &#40;0&#46;41&#37;&#41;&nbsp;\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 &#40;1&#46;2&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Infection</span>&nbsp;\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">&nbsp;\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">&nbsp;\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">&nbsp;\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="left" valign="middle">Site infection&nbsp;\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">1 &#40;0&#46;41&#37;&#41;&nbsp;\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">1 &#40;0&#46;41&#37;&#41;&nbsp;\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">&nbsp;\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="left" valign="middle">Secondary bacterial peritonitis&nbsp;\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">1 &#40;0&#46;41&#37;&#41;&nbsp;\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 &#40;0&#46;82&#37;&#41;&nbsp;\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">NS&nbsp;\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="left" valign="middle"><span class="elsevierStyleBold">Death</span>&nbsp;\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&nbsp;\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&nbsp;\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">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2078563.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Results and complications of large volume paracentesis whether performed by the nurse practitioner or a physician&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:18 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Deaths&#58; final data for 2006"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Heron M&#46;"
                            1 => "Hoyert D&#46;L&#46;"
                            2 => "Murphy S&#46;L&#46;"
                            3 => "Xu J&#46;"
                            4 => "Kochanek K&#46;D&#46;"
                            5 => "Tejada-Vera B&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Natl Vital Stat Rep"
                        "fecha" => "2009"
                        "volumen" => "57"
                        "paginaInicial" => "1"
                        "paginaFinal" => "135"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19788058"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Compensated cirrhosis&#58; natural history and prognostic factors"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Gines P&#46;"
                            1 => "Quintero E&#46;"
                            2 => "Arroyo V&#46;"
                            3 => "Teres J&#46;"
                            4 => "Bruguera M&#46;"
                            5 => "Rimola A&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "1987"
                        "volumen" => "7"
                        "paginaInicial" => "12"
                        "paginaFinal" => "18"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of the adult patient with cirrhosis due to ascites&#58; an update"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Runyon BA&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.22853"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2009"
                        "volumen" => "49"
                        "paginaInicial" => "2087"
                        "paginaFinal" => "2107"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19475696"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Care of patients with ascites"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Runyon BA&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM199402033300508"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "1994"
                        "volumen" => "330"
                        "paginaInicial" => "337"
                        "paginaFinal" => "342"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8277955"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Accuracy of polyp detection by gastroenterologies and nurse endoscopists during flexible sigmoidoscopy&#58; a randomized control trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Schenfeld P&#46;"
                            1 => "Lipscomb S&#46;"
                            2 => "Crook J&#46;"
                            3 => "Dominquez J&#46;"
                            4 => "Butler J&#46;"
                            5 => "Holmes L&#46;"
                            6 => "Cruess D&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "1999"
                        "volumen" => "117"
                        "paginaInicial" => "312"
                        "paginaFinal" => "318"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10419911"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Screening for colorectal cancer with flexible sigmoidoscopy by nonphysician endoscopists"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Wallace M&#46;B&#46;"
                            1 => "Kemp J&#46;A&#46;"
                            2 => "Meyer F&#46;"
                            3 => "Horton K&#46;"
                            4 => "Reffel A&#46;"
                            5 => "Christiansen C&#46;L&#46;"
                            6 => "Farraye FA&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J of Med"
                        "fecha" => "1999"
                        "volumen" => "107"
                        "paginaInicial" => "214"
                        "paginaFinal" => "218"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nurse endoscopy in a district general hospital"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Goodfellow P&#46;B&#46;"
                            1 => "Fretwell I&#46;A&#46;"
                            2 => "Simms JW&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1308/003588403321661343"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann R Coll Surg Engl"
                        "fecha" => "2003"
                        "volumen" => "85"
                        "paginaInicial" => "181"
                        "paginaFinal" => "184"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12831491"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nurse specialist led flexible sigmoidoscopy in an outpatient setting"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Kelly S&#46;B&#46;"
                            1 => "Murphy J&#46;"
                            2 => "Smith A&#46;"
                            3 => "Watson H&#46;"
                            4 => "Gibb S&#46;"
                            5 => "Walker C&#46;"
                            6 => "Reddy R&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1463-1318.2007.01271.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Colorectal Dis"
                        "fecha" => "2007"
                        "volumen" => "10"
                        "paginaInicial" => "390"
                        "paginaFinal" => "393"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17509042"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nurse led flexible sigmoidoscopy in primary care-the first thousand patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Maruthachalam K&#46;"
                            1 => "Stoker E&#46;"
                            2 => "Nicholson G&#46;"
                            3 => "Morgan AF&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1463-1318.2006.00973.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Colorectal Dis"
                        "fecha" => "2006"
                        "volumen" => "8"
                        "paginaInicial" => "557"
                        "paginaFinal" => "562"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16919106"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An evidence based manual for abdominal paracentesis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "McGibbon A&#46;"
                            1 => "Chen G&#46;I&#46;"
                            2 => "Peltekain K&#46;M&#46;"
                            3 => "van Zanten SV&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10620-007-9805-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dig Dis Sci"
                        "fecha" => "2007"
                        "volumen" => "52"
                        "paginaInicial" => "3307"
                        "paginaFinal" => "3315"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17393312"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Performance standards for therapeutic abdominal paracentesis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Grabau C&#46;M&#46;"
                            1 => "Crago S&#46;F&#46;"
                            2 => "Hoff L&#46;K&#46;"
                            3 => "Simon J&#46;A&#46;"
                            4 => "Melton C&#46;A&#46;"
                            5 => "Ott B&#46;J&#46;"
                            6 => "Kamath PS&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.20317"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2004"
                        "volumen" => "40"
                        "paginaInicial" => "484"
                        "paginaFinal" => "488"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15368454"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Capsule endoscopy examination - preliminary review by a nurse"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Niv Y&#46;"
                            1 => "Niv G&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Dig Dis and Sciences"
                        "fecha" => "2005"
                        "volumen" => "50"
                        "paginaInicial" => "2121"
                        "paginaFinal" => "2124"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Horrocks S&#46;"
                            1 => "Anderson E&#46;"
                            2 => "Salisbury C&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.324.7341.819"
                      "Revista" => array:6 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "2002"
                        "volumen" => "324"
                        "paginaInicial" => "819"
                        "paginaFinal" => "823"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11934775"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Patient satisfaction with outpatient hysteroscopy performed by nurse hysteroscopists"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Bodle J&#46;F&#46;"
                            1 => "Duffy S&#46;R&#46;G&#46;"
                            2 => "Binney DM&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J of Gyn and Obst"
                        "fecha" => "2008"
                        "volumen" => "103"
                        "paginaInicial" => "116"
                        "paginaFinal" => "200"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "McVay P&#46;A&#46;"
                            1 => "Toy PT&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Transfusion"
                        "fecha" => "1991"
                        "volumen" => "31"
                        "paginaInicial" => "164"
                        "paginaFinal" => "171"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1996485"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Paracentesis of ascitic fluid&#46; A safe procedure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Runyon BA&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Intern Med"
                        "fecha" => "1986"
                        "volumen" => "146"
                        "paginaInicial" => "2259"
                        "paginaFinal" => "2261"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2946271"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Safety of paracentesis in inpatients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:7 [
                            0 => "Duggal P&#46;"
                            1 => "Farah K&#46;F&#46;"
                            2 => "Anghel G&#46;"
                            3 => "Marcus R&#46;J&#46;"
                            4 => "Lupetin A&#46;R&#46;"
                            5 => "Babich M&#46;M&#46;"
                            6 => "Sandroni S&#46;E&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5414/cnp66171"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Nephrol"
                        "fecha" => "2006"
                        "volumen" => "66"
                        "paginaInicial" => "171"
                        "paginaFinal" => "176"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16995339"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Complications of diagnostic paracentesis in patients with liver disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Mallory A&#46;"
                            1 => "Schaefer JW&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
                        "fecha" => "1978"
                        "volumen" => "239"
                        "paginaInicial" => "628"
                        "paginaFinal" => "630"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/146097"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/16652681/0000000800000004/v1_201907070733/S1665268119317508/v1_201907070733/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "77721"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Original Article"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/16652681/0000000800000004/v1_201907070733/S1665268119317508/v1_201907070733/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119317508?idApp=UINPBA00004N"
]
Article information
ISSN: 16652681
Original language: English
The statistics are updated each day
Year/Month Html Pdf Total
2024 November 7 0 7
2024 October 50 11 61
2024 September 66 16 82
2024 August 62 16 78
2024 July 96 12 108
2024 June 60 11 71
2024 May 56 3 59
2024 April 51 4 55
2024 March 74 10 84
2024 February 103 4 107
2024 January 95 9 104
2023 December 79 3 82
2023 November 111 3 114
2023 October 114 11 125
2023 September 74 5 79
2023 August 64 2 66
2023 July 74 3 77
2023 June 79 4 83
2023 May 80 10 90
2023 April 75 0 75
2023 March 80 9 89
2023 February 29 7 36
2023 January 27 2 29
2022 December 44 7 51
2022 November 50 5 55
2022 October 44 14 58
2022 September 28 8 36
2022 August 39 6 45
2022 July 34 7 41
2022 June 20 5 25
2022 May 42 6 48
2022 April 29 14 43
2022 March 38 12 50
2022 February 34 3 37
2022 January 56 4 60
2021 December 27 8 35
2021 November 29 7 36
2021 October 39 6 45
2021 September 27 13 40
2021 August 25 6 31
2021 July 24 8 32
2021 June 15 9 24
2021 May 23 6 29
2021 April 91 18 109
2021 March 57 5 62
2021 February 31 8 39
2021 January 44 4 48
2020 December 36 8 44
2020 November 45 8 53
2020 October 31 6 37
2020 September 25 5 30
2020 August 32 3 35
2020 July 20 0 20
2020 June 17 3 20
2020 May 30 4 34
2020 April 25 2 27
2020 March 25 5 30
2020 February 35 1 36
2020 January 32 6 38
2019 December 26 5 31
2019 November 22 2 24
2019 October 26 5 31
2019 September 6 5 11
2019 August 3 1 4
2019 July 3 5 8
Show all

Follow this link to access the full text of the article

es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos