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Scientific letter
COVID was not to blame
No toda la culpa fue de la COVID
Ana Agudo-Tabuencaa,
Corresponding author
a.agudota@gmail.com

Corresponding author.
, Karla Gabriela Morales Campoverdeb, María Blanca García Garcíaa, Carlos Miguel Peteiro Mirandaa, Marta Sánchez Martelesc
a Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario “Lozano Blesa”, Zaragoza, Spain
b Servicio de Alergología, Hospital Clínico Universitario “Lozano Blesa”, Zaragoza, Spain
c Servicio de Medicina Interna, Hospital Clínico Universitario “Lozano Blesa”, Zaragoza, Spain
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with known atrial fibrillation confirmed by ECG at admission&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Previously&#44; the patient did not have fluid therapy&#46; Treatment with 300&#8239;mg of amiodarone was then started and urgent blood tests were requested&#44; highlighting hyponatraemia of 108&#8239;mEq&#47;l &#40;results in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; 2nd column&#44; with previous tests in 1&#8239;st column&#41;&#46; The patient was re-evaluated and still did not present any neurological abnormalities&#44; so admission to the ICU was ruled out and an infusion was started of 250&#8239;ml of 3&#37; hypertonic saline in four hours&#46; At that time&#44; thyroid dysfunction &#40;TSH&#58; 1&#46;62 mU&#47;l&#41; and adrenal insufficiency &#40;ACTH&#58; 24&#46;2&#8239;pg&#47;ml and basal cortisol&#58; 15 mcg&#47;dl&#41; were also ruled out&#46; The lab test results after four hours are reflected in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> &#40;3rd column&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">It was decided to leave an infusion of 500&#8239;ml 3&#37; hypertonic saline to be administered in eight hours&#46; After that&#44; lab tests were performed again&#44; including the N-terminal fraction of brain natriuretic peptide &#40;NT-proBNP&#41;&#58; 5350&#8239;pg&#47;ml &#40;previously 6830&#8239;pg&#47;ml&#41; &#40;rest of the parameters in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; 4th column&#41;&#46; On examination&#44; he presented with arterial hypertension &#40;172&#47;100&#8239;mmHg&#41; and controlled heart rate&#44; was afebrile and maintained a baseline oxygen saturation of 98&#37;&#46; There were no data on decompensated heart failure&#46; When questioned in a targeted manner&#44; he reported a daily intake of more than four litres of water&#44; with preserved diuresis &#40;he wore adult absorbent briefs at that time&#41; and an increase of up to five bowel movements in 24&#8239;h&#46; He had a good level of consciousness and in the rest of the examination only palpation of a non-painful infraumbilical mass stood out which was first assessed as possibly being a bladder overdistension&#44; but that was ruled out due to good daily diuresis&#46; At that time&#44; abdominal CT was requested to rule out underlying neoplasia&#46; The patient had undergone a pulmonary CT five days beforehand&#44; which ruled out the presence of pulmonary thromboembolism&#44; as well as neoplastic pathology&#44; reporting the presence of lesions consistent with the underlying infectious process&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The treatment with omeprazole was suspended&#44; as well as the daily furosemide tablet &#40;the diuretic had been previously decreased&#44; with decreasing NT-proBNP figures&#41; and a fluid restriction of one litre of water was indicated&#44; initiating an infusion of one litre of isotonic saline with two 10&#8239;ml ampoules of 20&#37; hypertonic saline after calculating the sodium deficit&#44; with a maximum correction objective of 8&#8239;mEq&#47;l in 24&#8239;h&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the control lab tests after eight hours&#44; renal function remained stable compared to previously&#44; and sodium was 121&#8239;mEq&#47;l&#46; At 24&#8239;h&#44; the patient was still asymptomatic&#44; without neurological deficit&#44; with unchanged physical examination and the same sensation of palpation of the infraumbilical mass&#46; The lab test results for that day are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> &#40;6th column&#41;&#46; Fluid restriction was maintained at one litre per day and perfusion of 1&#44;000&#8239;ml of isotonic saline in 24&#8239;h with three 10&#8239;ml ampoules of 20 &#37; hypertonic saline&#46; Abdominal CT only determined the presence of an overdistended bladder&#44; for which reason the patient was catheterised&#44; obtaining a total diuresis of 1&#44;800&#8239;ml&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Six hours after the new perfusion and catheterisation&#44; the lab test values were those shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> &#40;7th column&#41;&#44; for which hypertonic saline was suspended&#44; maintaining only isotonic saline&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The following day&#44; the patient was normotensive&#44; with a good heart rate&#44; with no neurological abnormalities and&#44; on examination&#44; the abdominal mass had disappeared&#46; The lab test results for that day are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> &#40;8th column&#41;&#46; For the rest of his hospital stay&#44; his blood sodium remained within normal levels and he did not develop complications secondary to the rapid correction of sodium after urinary catheterisation&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">This was a case of severe hyponatraemia secondary to acute asymptomatic urine retention&#44; with urinary incontinence due to overflow&#46; It was ruled out that hyponatraemia could be secondary to fluid overload &#40;absence of oedema&#44; normal lung auscultation&#44; no hepatic congestion or jugular engorgement&#41;&#46; It was unlikely that it was secondary to treatment with antiepileptic drugs &#40;phenobarbital and phenytoin&#41;&#44; as it was a chronic treatment without dose modification&#46; Hypothyroidism and adrenal insufficiency were ruled out&#46; Neither was it attributed to the COVID-19 infection itself&#44; since the most critical time period had passed and a clear relationship between COVID-19 infection and hyponatraemia has not been described for the time being&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Dehydration due to increased stool rhythm was not likely because the patient had presented only five not very large stools in the previous 24&#8239;h&#44; so syndrome of inappropriate secretion of antidiuretic hormone &#40;SIADH&#41; was initially considered&#44; despite the fact that the ion values in urine were not conclusive with this diagnosis&#46; With fluid restriction and hypertonic saline&#44; plasma sodium levels rose very slowly&#44; and following bladder catheterisation they quickly normalised&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">There are not many cases described in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a> Bladder distention is believed to cause release of vasopressin at the pituitary level&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Another theory supports the idea of saline loss due to resistance to the action of aldosterone at the renal tubular level due to an excess of sodium secretion in patients with obstructive uropathy&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> although in cases in which the obstruction dilates the urinary tract and renal calyces&#44; renal vasoconstriction occurs&#44; with decreased renal blood flow and decreased sodium arriving at the nephron&#46; This also causes renal failure with acute tubular necrosis&#44; in which urinary biochemical parameters are consistent with those found in the current case&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Therefore&#44; acute urinary retention should be considered in the differential diagnosis of hyponatraemia with low blood sodium levels that are not compatible with SIADH&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Data confidentiality</span><p id="par0060" class="elsevierStylePara elsevierViewall">The protocols established by the hospital have been followed in order to access data from the clinical history described in this case&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">No sponsorship of any kind was received for producing this article&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">Day &#8722;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">Day 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">Day 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">Day 2&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="left" valign="\n
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                  \t\t\t\t" scope="col">Day 2&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Day 3&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Day 3&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Day 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">6&#8239;pm&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">10&#8239;pm&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">8&#8239;am&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">9&#8239;pm&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">8&#8239;am&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">7&#8239;pm&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">8&#8239;am&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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Blood glucose &#40;mg&#47;dl&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">127&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">167&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">139&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">117&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">139&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urea &#40;g&#47;dl&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;2&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;9&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;89&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;78&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;79&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;72&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;68&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Creatinine &#40;mg&#47;dl&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;58&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;56&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;49&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;23&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;31&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;24&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sodium p &#40;mEq&#47;l&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">131&#46;5&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">108&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">110&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">121&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">124&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">130&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">142&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Potassium p &#40;mEq&#47;l&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;52&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;7&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">88&#46;2&nbsp;\t\t\t\t\t\t\n
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                  """
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lab test evolution of the patient in relation to the hours of evolution&#46;</p>"
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                            0 => "W&#46; Guan"
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                      "doi" => "10.1056/NEJMoa2002032"
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                        "tituloSerie" => "N Engl J Med"
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                      "titulo" => "Presenting characteristics&#44; comorbidities&#44; and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area"
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                          "etal" => false
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                            3 => "J&#46;M&#46; Crawford"
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                    0 => array:2 [
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                        "tituloSerie" => "Saudi J Kidney Dis Transplant"
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                        "numero" => "2"
                        "paginaInicial" => "392"
                        "paginaFinal" => "395"
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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