EDITORIAL
Medical care for spinal diseases during the COVID-19 pandemic
Ricardo Teixeira e Silva
, Alexandre Fogaça Cristante, Raphael Martus Marcon, Tarcísio Eloy Pessoa de Barros-Filho
Corresponding author
Instituto de Ortopedia e Traumatologia (IOT), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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"tienePdf" => "en" "tieneTextoCompleto" => "en" "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Diego Laurentino Lima, Maria Antonieta Albanez A de Medeiros Lopes, Ana Maria Brito" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Diego Laurentino" "apellidos" => "Lima" ] 1 => array:2 [ "nombre" => "Maria Antonieta Albanez A" "apellidos" => "de Medeiros Lopes" ] 2 => array:2 [ "nombre" => "Ana Maria" "apellidos" => "Brito" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222003787?idApp=UINPBA00004N" "url" => "/18075932/000000750000000C/v1_202211290815/S1807593222003787/v1_202211290815/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">EDITORIAL</span>" "titulo" => "Medical care for spinal diseases during the COVID-19 pandemic" "tieneTextoCompleto" => true "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ricardo Teixeira e Silva, Alexandre Fogaça Cristante, Raphael Martus Marcon, Tarcísio Eloy Pessoa de Barros-Filho" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Ricardo Teixeira" "apellidos" => "e Silva" "email" => array:1 [ 0 => "ricardo.teixeira.silva@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor1" ] ] ] 1 => array:2 [ "nombre" => "Alexandre Fogaça" "apellidos" => "Cristante" ] 2 => array:2 [ "nombre" => "Raphael Martus" "apellidos" => "Marcon" ] 3 => array:2 [ "nombre" => "Tarcísio Eloy Pessoa" "apellidos" => "de Barros-Filho" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Instituto de Ortopedia e Traumatologia (IOT), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR" "identificador" => "aff1" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Corresponding author." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="para10" class="elsevierStylePara elsevierViewall">Coronavirus disease (COVID-19), caused by the novel coronavirus (SARS-CoV-2), reached pandemic levels in March 2020, and has the potential to overburden health systems, compromise medical staff, and deplete essential hospital supplies. To minimize these adverse consequences and guarantee adequate treatment for patients with other conditions, it is necessary to develop balanced strategies <a class="elsevierStyleCrossRef" href="#bib1">1</a>. Healthcare professionals must be prepared for abrupt changes in the availability of hospital beds and human and material resources during this period, and must be aware that hospitals can become locations of elevated transmission of the disease <a class="elsevierStyleCrossRef" href="#bib2">2</a>.</p><p id="para20" class="elsevierStylePara elsevierViewall">Outpatient care should be restricted and performed only in cases of great need. The Brazilian Ministry of Health has temporarily authorized and regulated telemedicine activity in the country during the pandemic period. This decision may reduce the circulation of people and must be considered by doctors and health care services to preserve the health of patients and avoid overcrowding in health units <a class="elsevierStyleCrossRef" href="#bib3">3</a>.</p><p id="para30" class="elsevierStylePara elsevierViewall">Elective surgeries should be considered on a case-by-case basis, and postponed if possible. This action reduces unnecessary foot traffic in hospitals, reduces the spread of the disease, conserves hospital supplies, and preserves the health of surgical teams <a class="elsevierStyleCrossRef" href="#bib2">2</a>. Nevertheless, it is essential that health services develop strategies for performing urgent and emergency surgeries during the crisis period.</p><p id="para40" class="elsevierStylePara elsevierViewall">To guide specialists involved in the treatment of spinal disorders, this editorial summarizes the recommendations of the North American Spine Society <a class="elsevierStyleCrossRef" href="#bib4">4</a>, the American College of Surgeons <a class="elsevierStyleCrossRef" href="#bib5">5</a>, and the document signed by the Brazilian Spine Society, the Brazilian Society of Neurosurgery, and the Brazilian Society of Orthopedics and Traumatology <a class="elsevierStyleCrossRef" href="#bib6">6</a>(<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>).</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="para50" class="elsevierStylePara elsevierViewall">The characteristics of the COVID-19 pandemic are dynamic and distinct between regions and even between hospitals, therefore, therapeutic decisions must be individualized, and discussed with patients. The clinical condition of the patient and the availability of medical staff, personal protective equipment (PPE), and intensive care unit beds should be considered. Surgeons must also assess the risk of transmission of the virus in each region and in specific intrahospital sectors <a class="elsevierStyleCrossRef" href="#bib4">4</a>.</p><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">GENERAL CONSIDERATIONS FOR SURGICAL ASSISTANCE DURING THE COVID-19 PANDEMIC</span><p id="para60" class="elsevierStylePara elsevierViewall">It is essential that professionals who provide medical assistance during the pandemic receive adequate training to avoid the infection of patients, companions, and the medical team itself. Strategies for reducing the length of hospital stays and limiting the number of visitors should be encouraged, as well as the isolation of patients with COVID-19 in inpatient units and in operating rooms (ORs) <a class="elsevierStyleCrossRef" href="#bib2">2</a>. Handwashing and hand hygiene with alcohol-based solutions should be encouraged whenever necessary, and the use of disposable resources should be prioritized <a class="elsevierStyleCrossRef" href="#bib1">1</a>.</p><p id="para70" class="elsevierStylePara elsevierViewall">Health care professionals should constantly assess for respiratory symptoms, and patients with suspected or confirmed COVID-19 should be identified. Such patients must receive appropriate clinical evaluation to analyze the risks and benefits of the procedure and the most appropriate time to perform it <a class="elsevierStyleCrossRef" href="#bib2">2</a>. Lei et al. suggest that surgical procedures in patients infected with SARS-CoV-2, even if they are asymptomatic, are implicated in the development of more severe forms of the disease and a higher mortality rate <a class="elsevierStyleCrossRef" href="#bib7">7</a>.</p><p id="para80" class="elsevierStylePara elsevierViewall">The following are recommended for surgical procedures with patients who are suspected or confirmed cases of COVID-19: minimally invasive procedures with shorter operation times, careful and proper anesthetic planning to accelerate intubation and reduce manual ventilation, preference for the prone position to prevent droplet spread, minimization of the use and power of electrocautery, and avoidance of contamination of people and external materials with body fluids <a class="elsevierStyleCrossRef" href="#bib1">1</a>,<a class="elsevierStyleCrossRef" href="#bib8">8</a>.</p><p id="para90" class="elsevierStylePara elsevierViewall">Regarding the OR, the number of professionals involved in the surgical procedure and the circulation of people should be limited as much as possible. Ideally, everyone in the OR should use the following types of PPE: masks (n95/PFF2), long sleeve disposable coats, protective goggles or face shields, disposable caps, shoe covers, and disposable double pairs of gloves. Special attention must be given to donning and doffing procedures, as proper procedures are often neglected <a class="elsevierStyleCrossRef" href="#bib1">1</a>,<a class="elsevierStyleCrossRef" href="#bib8">8</a>.</p><p id="para100" class="elsevierStylePara elsevierViewall">Efforts must be made to reduce contact and proximity between patients and health professionals. Strategies to accomplish this include anesthetic recovery in the OR, short and planned intrahospital routes, restrictions on the number of professionals responsible for the internal transport of patients, and the avoidance of transfers between different hospital sectors. The use of disposable masks by patients is recommended during each of these steps <a class="elsevierStyleCrossRef" href="#bib1">1</a>,<a class="elsevierStyleCrossRef" href="#bib9">9</a>.</p><p id="para110" class="elsevierStylePara elsevierViewall">Strict techniques for the proper disposal of contaminated materials, the sanitization of ORs and surgical materials, and the maintenance of adequate ventilation systems must also be developed in cooperation with the internal hospital infection commission and clinical engineers <a class="elsevierStyleCrossRef" href="#bib1">1</a>,<a class="elsevierStyleCrossRef" href="#bib2">2</a>.</p><p id="para120" class="elsevierStylePara elsevierViewall">In summary, the COVID-19 pandemic is especially challenging due to the dual efforts to control the pandemic and simultaneously guarantee essential healthcare. The recommendations presented in this editorial may help spine surgeons to make decisions and should be analyzed carefully according to the evolution of the pandemic and the concerns of each region and hospital.</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">AUTHOR CONTRIBUTIONS</span><p id="para130" class="elsevierStylePara elsevierViewall">All authors participated equally in the realization of this work, both in the search for articles and in the writing and revision of the text.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "cesec10" "titulo" => "GENERAL CONSIDERATIONS FOR SURGICAL ASSISTANCE DURING THE COVID-19 PANDEMIC" ] 1 => array:2 [ "identificador" => "cesec20" "titulo" => "AUTHOR CONTRIBUTIONS" ] 2 => array:1 [ "titulo" => "REFERENCES" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-23" "fechaAceptado" => "2020-04-24" "NotaPie" => array:1 [ 0 => array:1 [ "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">No potential conflict of interest was reported.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Category \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Clinical Considerations \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Recommendation \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="\n \t\t\t\t\ttop\n \t\t\t\t">Emergent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Progressive or severe neurologic deficit due to neurologic compression from any cause (<span class="elsevierStyleItalic">e.g.</span>, infection, tumor, fracture, disc herniation, cauda equine syndrome)• Spinal instability at risk of causing neurologic injury from any cause (<span class="elsevierStyleItalic">e.g.</span>, fracture types B or C according to AO Spine Classification, tumor, infection)• Sepsis secondary to epidural abscess or spondylodiscitis    • Epidural hematoma    • Postoperative wound infection    • Cerebrospinal fluid leakage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Do not postpone the procedure/treatment.    - The surgical procedure must be performed within 24-48 hours. If this is not possible, the patient must be transferred to another center. \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="\n \t\t\t\t\ttop\n \t\t\t\t">Urgent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Refractory painful radiculopathies (secondary to conditions such as disc herniation, spinal stenosis, spondylolisthesis) requiring hospitalization    • Acute cervical or thoracic myelopathy    • Spine fractures without instability but with surgical indication (fracture types A3 and A4)    • Pathological fractures with instability (SINS > 12) but without neurological deficit    • Wound dehiscence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- If the conditions are favorable, the surgical procedure must be performed within 3-7 days.    - If this is not possible, the patient must be transferred to another center. \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="\n \t\t\t\t\ttop\n \t\t\t\t">Elective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Degenerative spinal disorders such as degenerative disc disease, some disc herniations, spinal stenosis, or spondylolisthesis, without significant neurologic deficit    • Hardware failure/pseudoarthrosis without neurological deficit or critical instability    • Scoliosis and/or kyphosis correction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Consider postponing the procedure/treatment until the pandemic is under control. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Spine surgery recommendations during the COVID-19 pandemic.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgery in COVID-19 patients: operational directives" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ F Coccolini \n \t\t\t\t\t\t\t\t """ 1 => """ G Perrone \n \t\t\t\t\t\t\t\t """ 2 => """ M Chiarugi \n \t\t\t\t\t\t\t\t """ 3 => """ F Di Marzo \n \t\t\t\t\t\t\t\t """ 4 => """ L Ansaloni \n \t\t\t\t\t\t\t\t """ 5 => """ I Scandroglio \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "World J Emerg Surg" "fecha" => "2020" "volumen" => "15" "numero" => "1" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "https://doi.org/10.1186/s13017-020-00307-2" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Managing COVID-19 in Surgical Systems" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ M Brindle \n \t\t\t\t\t\t\t\t """ 1 => """ A Gawande \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Ann Surg" "fecha" => "2020" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "https://doi.org/10.1097/SLA.0000000000003923" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ministério da Saúde (BR). 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Dispõe, em caráter excepcional e temporário, sobre as ações de Telemedicina, com o objetivo de regulamentar e operacionalizar as medidas de enfrentamento da emergência de saúde pública de importância internacional previstas no art. 3° da Lei n° 13.979, February 6th, 2020, decorrente da epidemia de COVID-19 Diário Oficial União 23/03/2020 | Edição: 56-B | Seção 1" ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "NASS Guidance Document on Elective, Emergent and Urgent Procedures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => """ North American Spine Society \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:1 [ "link" => "Available from: https://www.spine.org/Portals/0/assets/downloads/Publications/NASSInsider/NASSGuidanceDocument040320.pdf" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ACS recommendations for management of elective surgical procedures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => """ American College of Surgeons \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:1 [ "link" => "Available from: https://www.facs.org/covid-19/clinical-guidance/elective-surgery" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Documento conjunto SBC, SBN, SBOT referente a prioridades terapêuticas em cirurgia de coluna durante o período de crise relacionado a COVID-19" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => """ Sociedade Brasileira de Coluna, Sociedade Brasileira de Neurocirurgia, Sociedade Brasileira de Ortopedia e Traumatologia \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:1 [ "link" => "Available from: http://portalsbc.org/documento-conjunto-sbc-sbn-sbot-referente-a-prioridades-terapeuticas-em-cirurgia-de-coluna-durante-o-periodo-de-crise-relacionado-ao-covid-19/" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ S Lei \n \t\t\t\t\t\t\t\t """ 1 => """ F Jiang \n \t\t\t\t\t\t\t\t """ 2 => """ W Su \n \t\t\t\t\t\t\t\t """ 3 => """ C Chen \n \t\t\t\t\t\t\t\t """ 4 => """ J Chen \n \t\t\t\t\t\t\t\t """ 5 => """ W Mei \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "EClinicalMedicine" "fecha" => "2020" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "https://doi.org/10.1016/j.eclinm.2020.100331" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Advice on Standardized Diagnosis and Treatment for Spinal Diseases during the Coronavirus Disease 2019 Pandemic" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => """ J Zou \n \t\t\t\t\t\t\t\t """ 1 => """ H Yu \n \t\t\t\t\t\t\t\t """ 2 => """ D Song \n \t\t\t\t\t\t\t\t """ 3 => """ J Niu \n \t\t\t\t\t\t\t\t """ 4 => """ H Yang \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.31616/asj.2020.0122" "Revista" => array:7 [ "tituloSerie" => "Asian Spine J" "fecha" => "2020" "volumen" => "14" "numero" => "2" "paginaInicial" => "258" "paginaFinal" => "263" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32222720" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.31616/asj.2020.0122" "WWW" => array:1 [ "link" => "https://doi.org/10.31616/asj.2020.0122" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Precautions for Operating Room Team Members During the COVID-19 Pandemic" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ JD Forrester \n \t\t\t\t\t\t\t\t """ 1 => """ AK Nassar \n \t\t\t\t\t\t\t\t """ 2 => """ PM Maggio \n \t\t\t\t\t\t\t\t """ 3 => """ MT Hawn \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "J Am Coll Surg" "fecha" => "2020" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "https://doi.org/10.1016/j.jamcollsurg.2020.03.030" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/18075932/000000750000000C/v1_202211290815/S1807593222003799/v1_202211290815/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/18075932/000000750000000C/v1_202211290815/S1807593222003799/v1_202211290815/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222003799?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 16 | 19 | 35 |
| 2024 September | 35 | 25 | 60 |
| 2024 August | 52 | 19 | 71 |
| 2024 July | 28 | 36 | 64 |
| 2024 June | 28 | 11 | 39 |
| 2024 May | 39 | 17 | 56 |
| 2024 April | 35 | 14 | 49 |
| 2024 March | 33 | 15 | 48 |
| 2024 February | 39 | 18 | 57 |
| 2024 January | 27 | 12 | 39 |
| 2023 December | 18 | 17 | 35 |
| 2023 November | 16 | 21 | 37 |
| 2023 October | 15 | 28 | 43 |
| 2023 September | 14 | 27 | 41 |
| 2023 August | 32 | 5 | 37 |
| 2023 July | 12 | 18 | 30 |
| 2023 June | 21 | 19 | 40 |
| 2023 May | 35 | 1 | 36 |
| 2023 April | 42 | 0 | 42 |
| 2023 March | 26 | 2 | 28 |
| 2023 February | 15 | 0 | 15 |
| 2023 January | 5 | 1 | 6 |
| 2022 December | 17 | 2 | 19 |
| 2022 November | 1 | 0 | 1 |
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