Appropriateness of routine pre-endoscopic SARS-CoV-2 screening with RT-PCR in asymptomatic individuals and its impact on delayed diagnosis | Gastroenterología y Hepatología (English Edition)

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">As of November 2021&#44; infection with severe acute respiratory syndrome coronavirus 2 &#40;SARS-CoV-2&#41; causing coronavirus disease 2019 &#40;COVID-19&#41; has occurred in more than 290&#44;000&#44;000 people and caused over 5&#44;400&#44;000 deaths globally&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> Although the most commonly described symptoms are fever and cough&#44; a recent meta-analysis found that gastrointestinal symptoms were reported in up to 18&#37; of patients with COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> Although the transmission of SARS-CoV-2 occurs most commonly through the inhalation of aerosols or droplets&#44; some studies have described that angiotensin converting enzyme 2 receptor &#40;a membrane receptor supporting the entry of SARS-CoV-2 into the cell&#41; is expressed in the glandular digestive epithelia&#44; leading to the possibility of fecal-oral transmission&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Endoscopy units are considered to be at an increased risk of infection by SARS-CoV-2&#44; not only because of the inhalation of airborne droplets or conjunctival contact but also because of potential fecal-oral transmission&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> For this reason&#44; most of the endoscopy units worldwide decreased &#40;or even stopped&#41; their activity during the first wave of the pandemia&#44; delaying many elective examinations and the diagnosis of potentially life-threatening conditions&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">6&#44;7</span></a> In fact&#44; a substantial reduction in the diagnosis of new gastrointestinal cancers has already been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a> National and international endoscopy societies have proposed recommendations regarding the reopening of endoscopy units&#46; These recommendations include pre-procedure testing&#44; health-professional personal protective equipment &#40;PPE&#41; and prioritization rules for endoscopic examinations&#46; Nevertheless&#44; there is currently no consensus on the use of routine SARS-CoV-2 testing with reverse transcription polymerase chain reaction &#40;RT-PCR&#41; or antigen-tests for asymptomatic individuals scheduled for endoscopic procedures&#46; The European Society of Gastrointestinal Endoscopy and the European Society of Gastroenterology and Endoscopy Nurses and Associates proposed that all patients be required to provide a negative viral test &#40;RT-PCR&#41; performed within 48<span class="elsevierStyleHsp" style=""></span>h before endoscopy or either documentation of full vaccination status or recovery from COVID-19 infection within the past 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a> The Spanish Gastroenterology societies proposed checking every patient for fever and asking about symptoms such as fever or cough before endoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> Finally&#44; the American Gastroenterological Association recommended against routine testing irrespective of the vaccination status of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Nasopharyngeal and throat swabs are widely used to perform SARS-CoV-2 RT-PCR tests on asymptomatic patients as it identifies viral RNA rather than viral infection status&#46; A meta-analysis including seven studies observed a sensitivity of 73&#46;3&#37; and a specificity of 95&#37; for this test&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> Recent studies have demonstrated that SARS-CoV-2 transmission is feasible from people who suffered asymptomatic infection &#40;SARS-CoV-2 detected but symptoms not developed&#41; or during the pre-symptomatic phase &#40;SARS-CoV-2 detected before symptom onset&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> However&#44; more studies evaluating selective screening strategies to optimize the resources are needed&#44; considering that universal screening with RT-PCR may not be available in all centers&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The primary aim of this study is to describe the results of routine pre-endoscopic screening in our endoscopy unit and to correlate them with the administrative epidemiological data of our background population&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We conducted an observational&#44; retrospective study of routine pre-endoscopic SARS-CoV-2 RT-PCR screening carried out at our center from June 2020 to June 2021 &#40;comprising from the second to the fourth pandemic wave in Spain&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">All adult individuals scheduled for an outpatient elective endoscopic procedure underwent mandatory SARS-CoV-2 RT-PCR testing &#40;Panther Fusion&#44; Hologic and Procleix Panther&#44; Grifols&#44; Spain&#41; performed at our center by nasopharyngeal swab in the 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h prior to endoscopy&#46; In order to ensure all individuals were asymptomatic&#44; they were contacted by telephone at least 7 days before the endoscopy and they were specifically advised not to assist to the mandatory RT-PCR if they presented cough&#44; fever&#44; dyspnea&#44; asthenia or anosmia from the day of the calling until the day of the RT-PCR&#46; In case they presented any of these symptoms&#44; the procedure were adjourned 30 days&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">All endoscopic procedures were performed using PPE that included full body gown&#44; FFP &#40;filtering face pieces&#41; type 2 face mask&#44; gloves&#44; face shield and cap&#46; Patients who tested positive were individually evaluated to reschedule the procedure at least 30 days later and only high-priority indications were performed regardless of the test result&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Individuals with a negative test answered a survey on the day of the endoscopy regarding COVID-19 related-symptoms and close contacts within the previous week&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">RT-PCR results and time between the screening test and the endoscopic procedure were registered&#46; Demographic data&#44; SARS-CoV-2 vaccination status&#44; SARS-CoV-2 related symptoms &#40;fever&#44; cough&#44; dyspnea&#44; asthenia and anosmia&#41;&#44; indication for endoscopy&#44; delay &#40;if needed&#41; and endoscopic findings were all recorded in the case of a positive RT-PCR result&#46; Epidemiological data in our healthcare area &#40;northern metropolitan area of Barcelona&#41; were obtained from the Catalan Health Department website&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> During the study period&#44; 7 and 14-day cumulative incidence &#40;CI&#41; and the weekly effective potential growth index &#40;EPG&#41; were retrieved&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The EPG was developed by a multidisciplinary team to measure the probability of new disease outbreaks based on the 14-day CI and disease propagation rate &#40;R0&#41; which was used to define local restrictions&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> The risk of disease outbreak is stratified into five main stages&#58; low risk &#40;EPG<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30&#41;&#44; low-medium risk &#40;EPG 30&#8211;70&#41;&#44; medium-high risk &#40;EPG 70&#8211;100&#41;&#44; high risk &#40;EPG 100&#8211;200&#41; and very high risk &#40;EPG<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>200&#41;&#46; We grouped the results of RT-PCR tests in a weekly and biweekly manner&#46; In relation to the scheduled endoscopic procedure&#44; the EPG was retrieved for three different time points&#58; the first day of the same week &#40;EPG-0&#41; of the scheduled procedure&#44; the first day of the previous week &#40;EPG-1&#41; and the first day of the week two weeks before &#40;EPG-2&#41;&#46; CI values for seven &#40;7CI&#41; and 14 days &#40;14CI&#41; were retrieved in the same way &#40;7CI-0&#44; 7CI-1&#44; 7CI-2&#44; 14CI-0&#44; 14CI-1&#44; 14CI-2&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Quantitative variables are presented as mean and standard deviation or median and interquartile range &#40;IQR&#41;&#44; depending on their distribution&#46; Categorical variables are presented as raw numbers and proportions&#46; Categorical variables were compared using the Chi<span class="elsevierStyleSup">2</span>-squared test&#46; The Saphiro&#8211;Wilk test was performed to examine the normality of continuous variables&#46; To evaluate the correlation between continuous variables&#44; Spearman tests were performed&#46; All statistical analyses were performed using SPSS statistics software &#40;Version 25&#46;0&#44; IBM&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results of the routine screening and correlation with epidemiological indexes</span><p id="par0060" class="elsevierStylePara elsevierViewall">During the study period &#40;52 weeks&#41;&#44; 5808 RT-PCR tests were performed on 5112 individuals as screening for a planned endoscopic procedure&#46; Of these&#44; 125 tests &#40;0&#46;15&#37;&#41; on 113 individuals yielded positives&#46; A mean number of 113<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#46;78 tests were performed per week and the mean time interval from RT-PCR to endoscopy was 2&#46;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;76 days&#46; The rate of positive tests was 1&#46;71&#37; &#40;49&#47;2859&#41; during the second pandemic wave &#40;from the end of June 2020 to the beginning of December 2020&#41;&#44; 4&#46;10&#37; &#40;60&#47;1456&#41; during the third wave &#40;December 2020 to March 2021&#41; and 1&#46;08&#37; &#40;16&#47;1484&#41; during the fourth &#40;March 2021 to June 2021&#41;&#46; The highest weekly rate of positive tests was observed in January 2021&#44; reaching 9&#46;36&#37; &#40;5&#47;54&#41;&#46; All retrieved data is exposed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Thirty-six weeks of the study period were considered to be very high risk&#44; nine weeks high risk&#44; three medium-high risk&#44; two medium-low risk and two low risk&#46; All positive RT-PCR tests were registered during high or very high-risk weeks&#46; The cumulative rate of positive tests in high-risk weeks was 0&#46;92&#37; &#40;9&#47;982&#41;&#44; and 2&#46;88&#37; &#40;116&#47;3913&#41; in very high-risk weeks &#40;a summary of the stratified RT-PCR results is provided in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The cumulative proportion of positive RT-PCR tests was significantly lower when screening was performed during low&#44; medium-low and medium-high risk weeks compared to high and very high-risk weeks &#40;0&#37; vs&#46; 2&#46;50&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">According to EPG-1 &#40;one week before the planned endoscopy&#41;&#44; seven weeks had an EPG-1<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100 &#40;low&#44; medium-low or medium-high risk&#41; with 1&#47;826 positive tests &#40;0&#46;12&#37;&#41;&#46; The remaining 45 weeks had an EPG-1<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100 &#40;high or very high risk&#41; with 124&#47;4982 positive tests &#40;2&#46;49&#37;&#41;&#46; Using the same approach&#44; according to EPG-2 &#40;two weeks before the planned endoscopy&#41;&#44; seven weeks had an EPG-2<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100 with 1&#47;764 positive tests &#40;0&#46;13&#37;&#41; and 45 weeks had an EPG-2<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100 with 124&#47;5044 &#40;2&#46;46&#37;&#41;&#46; The cumulative rate of positive tests in high or very-high risk weeks was significantly higher taking into account both EPG-1 and EPG-2 &#40;2&#46;49&#37; vs&#46; 0&#46;02&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001 and 2&#46;45 vs&#46; 0&#46;13&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001 respectively&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the Chi2-squared test contingency tables of the three groups&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The correlation between positive rates &#40;grouped weekly and biweekly&#41; and epidemiological data &#40;7CI&#44; 14CI and EPG&#41; in three different moments &#40;current week&#44; previous week and two weeks prior&#41; was statistically significant in all the Spearman correlation tests &#40;results of all Spearman tests can be seen in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; The biweekly positive rate and the epidemiological data of the corresponding week &#40;7CI-0&#44; 14CI-0 and EPG-0&#41; showed a strong correlation &#40;rho<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;7&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; whereas the remaining tests showed moderate correlations &#40;rho 0&#46;5&#8211;0&#46;7&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> showing scatterplots with strong correlation&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Impact of positive screening on patients&#8217; diagnosis</span><p id="par0080" class="elsevierStylePara elsevierViewall">As mentioned above&#44; 113 individuals tested positive during the study period&#44; only one of whom &#40;0&#46;88&#37;&#41; was fully vaccinated&#44; while 20 &#40;17&#46;7&#37;&#41; developed COVID-19 symptoms following the test &#40;cough 50&#37;&#59; dyspnea&#44; asthenia and anosmia 25&#37; each&#41;&#46; Endoscopy was adjourned in 83&#47;113 &#40;73&#46;5&#37;&#41; individuals with a median of 50 &#40;IQR 41&#8211;68&#41; days&#59; in 6&#47;113 &#40;5&#46;3&#37;&#41; endoscopy was performed with PPE&#44; and postponed and not yet performed in 24&#47;113 &#40;21&#46;2&#37;&#41;&#46; Pathological findings were observed in 24&#47;89 &#40;27&#37;&#41; of the endoscopic examinations&#44; 21&#47;83 &#40;25&#46;3&#37;&#41; in delayed explorations and 3&#47;6 &#40;50&#37;&#41; in non-delayed ones&#46; The most common diagnostics among delayed examinations were colonic polyps &#40;nine patients&#41;&#44; colorectal cancer &#40;CRC&#41; &#40;three patients&#41; and gastric metaplasia &#40;three patients&#41;&#46; In non-delayed examinations&#44; the pathological findings were a cytomegalovirus colitis in a patient diagnosed with ulcerative colitis&#44; a new diagnosis of ulcerative colitis and non-specific ileitis&#46; Oncological diagnosis was delayed in three patients &#40;renamed as patients A&#44; B&#44; C&#41;&#44; with a mean delay of 57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&#46;6 days&#46; Patient A was a 43-year-old male with no past medical history&#46; A colonoscopy was requested because of constipation and was delayed for 31 days&#46; The diagnosis was a stage IV CRC &#40;pT4N1M1&#41; and urgent placement of an endoprosthesis was required&#46; Patient B was a 77-year-old male with metabolic syndrome&#44; coronary heart disease and skin squamous cell carcinoma undergoing oral antiplatelet treatment&#46; The indication for the endoscopic examination was iron-deficiency anemia&#44; which was delayed 94 days&#46; The final diagnoses were stage II CRC &#40;pT2N0M0&#41; and synchronic stage III pancreatic carcinoma &#40;pT2N1M0&#41;&#46; Although colonic and pancreatic surgeries&#44; as well as adjuvant chemotherapy&#44; were performed&#44; the patient passed away nine months later&#46; Patient C was a 77-year-old female with arterial hypertension and congenital cognitive impairment&#46; The endoscopic indication was the scheduled resection of a large polyp in the rectum which was delayed 48 days&#59; ultimately only biopsies were taken according to optical diagnostic criteria&#46; The final diagnosis was stage IV CRC &#40;pT1N0M1&#41; for which the patient underwent surgical treatment&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">National and international gastrointestinal endoscopy societies mainly recommended against universal RT-PCR screening SARS-CoV-2 in asymptomatic individuals before endoscopy based on the scarce available evidence&#44; the heterogeneity of the published studies and some additional drawbacks such as cost&#44; delays in care&#44; impact on cancer burden and the consequences of false positive and negative results&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">9&#8211;11</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Even though the adoption of protective measures substantially diminishes the risk of transmission during the endoscopic procedure&#44; the identification of asymptomatic carriers allows for the protection from infection of not only health professionals but also of health care users who share common facilities&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> Beyond the immediate consequences of disease transmission&#44; sick leaves by health professionals usually lead to increased delays in the provision of health care services&#46; Similar studies evaluating the prevalence of pre-endoscopic positive RT-PCR among asymptomatic individuals in different periods of the pandemic exhibited low rates ranging from 0&#37; to 1&#46;5&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">17&#8211;21</span></a> contrasting with our study in which a total prevalence of 2&#46;15&#37; was observed&#46; This difference may be explained by the markedly higher number of tests and longer study period of our study&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">From an economic point of view&#44; Corral et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> conducted a study evaluating different screening strategies and concluded that RT-PCR screening before endoscopy is an effective strategy to restart endoscopic activity&#44; underlining that disease prevalence is the most determining factor to support its effectiveness&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In our cohort&#44; no positive RT-PCR results were registered out of high-risk periods&#46; We found a significant correlation between the rate of positive tests and local epidemiological data&#44; not only from the collected data on the same week&#44; as expected&#44; but also from the data of one and two weeks before the screening test&#46; These findings may allow us to plan the screening based on local epidemiological indexes&#44; particularly EPG since it takes into account not only 14CI but also R0&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Hypothetically&#44; if the screening had been planned according to EPG<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100 took from 1 week before and 2 weeks before &#40;EPG-1 and EPG-2&#44; respectively&#41;&#44; up to 826 and 763 tests would have been avoided&#44; which would have accounted for only one positive result during the weeks considered of lower risk&#46; Even though it is a non-negligible number of avoidable tests&#44; identifying one positive result meant testing over 46 individuals&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">We also aimed to assess the impact of our screening strategy on oncological diagnostic delays&#44; one of the most feared consequences of the pandemic&#46; Despite the potential negative impact of any screening strategy for SARS-CoV-2&#44; the individual evaluation of patients with positive RT-PCR and the implementation of prioritization strategies resulted in oncological diagnostic delay in three cases among almost 6000 planned endoscopies&#46; Some authors suggest that delays as short as three months in cancer diagnosis might significantly impact on patients&#8217; long-term survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">23&#44;24</span></a> These statements are based on a computational model simulation and take into account only advanced and aggressive cancers&#46; In contrast&#44; cancers with overall good prognosis&#44; such as colorectal&#44; kidney and breast cancers&#44; would not suffer such an impact on short delays&#46; Similarly&#44; Zorzi et al&#46; described in a recent study that delays shorter than 270 days on CRC diagnosis after a positive result of fecal immunochemical test screening did not have a significant impact on staging nor on long-term survival&#46; Even though study populations are not comparable&#44; these remarks suggest that potential COVID-19 screening-related diagnostic delays might not have such a significant impact if strict prioritization strategies are implemented&#46; In our study population&#44; oncological diagnoses were delayed a maximum of 94 days and deeper evaluation of the individual medical record might even have resulted in even shorter delays&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Our study has several limitations&#46; First&#44; our screening strategy did not take into account whether individuals were fully or partially vaccinated&#44; previous history of COVID-19 infection or recent negative antigen or RT-PCR tests&#44; factors that may well decrease pre-test probability and should probably be taken into account in an optimal screening strategy design&#46; Second&#44; the epidemiological data from the Catalan Health Department are calculated based on a population tested mainly under a consistent suspicion of SARS-CoV-2 infection and&#44; therefore&#44; it is not strictly equivalent to our asymptomatic cohort&#46; Finally&#44; several health professionals in our endoscopy unit were diagnosed with COVID-19 or asymptomatic SARS-CoV-2 infection&#46; Although most of these infections seemed to be related to contacts outside our unit&#44; no particular investigations beyond testing co-workers were performed to rule out the unit as the origin of the infection&#46; In contrast&#44; the length and sample size of our study&#44; together with the availability of a symptomatic and epidemiological survey of all the individuals with negative screening&#44; are factors that strengthen our results&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; to the best of our knowledge&#44; this study constitutes the largest retrospective study to date of universal RT-PCR SARS-CoV-2 pre-endoscopic screening in asymptomatic patients spanning one year and three waves of the pandemic&#46; Planning tests based on the EPG index&#44; due to its correlation with screening results&#44; may be a cost-effective strategy to optimize material and human resources and avoid unnecessary tests&#46; Nonetheless&#44; two full years have passed since the COVID-19 was described and the scenario we currently face is far different from the one on which the screening programs were designed and thus they should be periodically updated&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethics standard statement</span><p id="par0125" class="elsevierStylePara elsevierViewall">The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards&#46; The data was anonymized from the authors according to data protection regulation&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">None to declare&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">None to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Aims</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Endoscopy units are considered to be at an increased risk of infection by SARS-CoV-2&#46; Our aim is to assess the correlation between pre-endoscopic screening with reverse-transcription-polymerase-chain-reaction &#40;RT-PCR&#41; in asymptomatic individuals scheduled for elective endoscopy and the epidemiological data published by the local Health Administration&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Observational retrospective study collecting the results of our screening strategy spanning June&#47;2020&#8211;June&#47;2021&#44; the effective potential growth &#40;EPG&#41;&#44; an index measuring the outbreak risk&#44; and the 7 and 14-day cumulative incidence &#40;CI&#41;&#46; Indication&#44; delay and the findings of the endoscopic examinations were registered for RT-PCR positive patients&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 5808 tests were performed&#44; yielding 125 positive results &#40;2&#46;15&#37;&#41;&#46; All positive tests occurred in weeks of high&#47;very high risk &#40;EPG<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100&#41; with the highest monthly rate being 9&#46;36&#37;&#44; recorded in January&#47;2021&#46; A significant correlation &#40;rho<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;796&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; between weekly positive rates and EPG was observed&#44; and a significantly lower weekly number of positive tests was recorded when EPG<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100&#46; Planning the screening strategy one week ahead according to EPG<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100 would have avoided up to 826 tests with only one positive result to account for&#46; One hundred and thirteen individuals tested positive and 89 endoscopies were delayed&#46; The most common findings were colon polyps&#44; colorectal cancer and gastric metaplasia&#46; Oncological diagnosis was delayed 50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3 days&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">No positive RT-PCR test were registered out of high-risk periods&#46; Epidemiological administrative data in the preceding two weeks showed a significant correlation with screening results and could be useful to plan pre-endoscopic screening and avoid unnecessary tests&#46;</p></span>"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La actividad endosc&#243;pica comporta un riesgo elevado de transmisi&#243;n de la infecci&#243;n por SARS-CoV-2&#46; Nuestro objetivo es valorar la correlaci&#243;n entre el cribado pre-endosc&#243;pico con <span class="elsevierStyleItalic">reverse-transcription-polymerase-chain-reaction</span> &#40;RT-PCR&#41; en individuos asintom&#225;ticos programados para una endoscopia ambulatoria y los datos epidemiol&#243;gicos publicados por el departamento de salud p&#250;blica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo de los resultados del cribado realizado entre junio&#47;2020 y junio&#47;2021&#46; Se registr&#243; el &#237;ndice de crecimiento potencial &#40;ICP&#41; y la incidencia acumulada a 7 y 14 d&#237;as&#46; En los pacientes con RT-PCR positiva se registraron indicaci&#243;n&#44; demora y hallazgos endosc&#243;picos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se identificaron un total de 5&#46;808 test con 125 resultados positivos &#40;2&#44;15&#37;&#41;&#46; Todos los resultados positivos se registraron en semanas consideradas de alto&#47;muy alto riesgo &#40;ICP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100&#41;&#44; con una tasa m&#225;xima de positivos del 9&#44;26&#37; en enero&#47;2021&#46; Se observ&#243; una correlaci&#243;n significativa &#40;rho<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;796&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; entre la tasa de positivos y el ICP&#44; as&#237; como una diferencia estad&#237;sticamente significativa con la tasa de positivos en las semanas con el ICP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100&#46; Planificar el cribado acorde al ICP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100 en la semana previa&#44; habr&#237;a evitado hasta 876 test&#44; con un &#250;nico resultado positivo&#46; Ciento trece pacientes resultaron positivos y se demoraron 89 endoscopias&#59; los hallazgos m&#225;s frecuentes fueron p&#243;lipos&#44; c&#225;ncer colorrectal y metaplasia g&#225;strica&#46; El diagn&#243;stico oncol&#243;gico se demor&#243; 50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3 d&#237;as&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">No se registraron RT-PCR positivas fuera de los per&#237;odos de alto riesgo&#46; Los datos epidemiol&#243;gicos de las dos semanas anteriores mostraron una correlaci&#243;n significativa con los resultados del cribado y podr&#237;an ser &#250;tiles para planificar el mismo y evitar pruebas innecesarias&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Antecedentes"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Pacientes y m&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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        "etiqueta" => "Figure 1"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Spearman test scatterplots for strong correlation&#46; EPG-0&#58; Effective potential growth of the same period&#46; 7CI-0&#58; Seven-day cumulative incidence of the same period&#46; 14CI-0&#58; Fourteen-day cumulative incidence of the same period&#46;</p>"
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3175691.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">RT-PCR results and EPG value&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Low risk&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" style="border-bottom: 2px solid black">Medium&#8211;low risk&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">High risk&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" style="border-bottom: 2px solid black">Very high risk&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" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">N&#176; weeks&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">52&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">Positive RT-PCR&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">116&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">125&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">Negative RT-PCR&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">160&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">283&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">354&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">973&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3913&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5683&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">Total RT-PCR&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">160&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">283&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">354&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">982&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4029&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5808&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">Positive rate&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;92&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;88&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;15&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">RT-PCR results according to EPG risk index&#46;</p>"
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      ]
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">EPG-0&#58; Effective potential growth of the same week&#46; EPG-1&#58; Effective potential growth from one week before&#46; EPG-2&#58; Effective potential growth from two weeks before&#46;</p>"
          "tablatextoimagen" => array:3 [
            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">EPG-0<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100&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">EPG-0<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100&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">Positive result&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">125&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&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">Negative result&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4886&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">797&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">EPG-1<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100&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">EPG-1<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100&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">Positive result&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="char" 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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&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">Negative result&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4858&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">825&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            2 => 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
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">EPG-2<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100&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">EPG-2<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100&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">Positive result&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="char" 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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \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">Negative result&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4920&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">763&nbsp;\t\t\t\t\t\t\n
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                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Chi<span class="elsevierStyleSup">2</span>-squared contingency tables of risk-stratified weeks&#46;</p>"
        ]
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      4 => array:8 [
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          0 => array:3 [
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        "tabla" => array:2 [
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Weekly positive rate vs&#46;</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">EPG-0&nbsp;\t\t\t\t\t\t\n
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              "identificador" => "bib0125"
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                  "referenciaCompleta" => "European Centre for Disease Prevention and Control&#46; COVID-19 situation update worldwide&#46; Available from&#58; <a target="_blank" href="https://www.ecdc.europa.eu/en/geographical-distribution-2019-ncov-cases">https&#58;&#47;&#47;www&#46;ecdc&#46;europa&#46;eu&#47;en&#47;geographical-distribution-2019-ncov-cases</a> &#91;accessed 23&#46;1&#46;22&#93;&#46;"
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                      "titulo" => "Gastrointestinal manifestations of SARS-CoV-2 infection and virus load in fecal samples from a Hong Kong cohort&#58; systematic review and meta-analysis"
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                          "etal" => true
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                            0 => "K&#46;S&#46; Cheung"
                            1 => "I&#46;F&#46;N&#46; Hung"
                            2 => "P&#46;P&#46;Y&#46; Chan"
                            3 => "K&#46;C&#46; Lung"
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                            5 => "R&#46; Liu"
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                      "doi" => "10.1053/j.gastro.2020.03.065"
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                        "tituloSerie" => "Gastroenterology"
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                        "volumen" => "159"
                        "paginaInicial" => "81"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32251668"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Expression of the SARS-CoV-2 cell receptor gene ACE2 in a wide variety of human tissues"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46;Y&#46; Li"
                            1 => "L&#46; Li"
                            2 => "Y&#46; Zhang"
                            3 => "X&#46;S&#46; Wang"
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                      "doi" => "10.1186/s40249-020-00662-x"
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                        "tituloSerie" => "Infect Dis Poverty"
                        "fecha" => "2020"
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                      "titulo" => "Evidence for gastrointestinal infection of SARS-CoV-2"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "F&#46; Xiao"
                            1 => "M&#46; Tang"
                            2 => "X&#46; Zheng"
                            3 => "Y&#46; Liu"
                            4 => "X&#46; Li"
                            5 => "H&#46; Shan"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1053/j.gastro.2020.02.055"
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                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2020"
                        "volumen" => "158"
                        "paginaInicial" => "1831"
                        "paginaFinal" => "1833"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32142773"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Review article&#58; gastrointestinal features in COVID-19 and the possibility of faecal transmission"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Y&#46; Tian"
                            1 => "L&#46; Rong"
                            2 => "W&#46; Nian"
                            3 => "Y&#46; He"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/apt.15731"
                      "Revista" => array:6 [
                        "tituloSerie" => "Aliment Pharmacol Ther"
                        "fecha" => "2020"
                        "volumen" => "51"
                        "paginaInicial" => "843"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32222988"
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                      "titulo" => "Colorectal cancer screening and COVID-19"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S&#46; Patel"
                            1 => "R&#46;B&#46; Issaka"
                            2 => "E&#46; Chen"
                            3 => "M&#46; Somsouk"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.14309/ajg.0000000000000970"
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                        "tituloSerie" => "Am J Gastroenterol"
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                        "paginaInicial" => "433"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33038127"
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                      "titulo" => "COVID-19 and endoscopic management of superficial gastrointestinal neoplastic lesions&#58; a multinational cross-sectional survey"
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                          "etal" => true
                          "autores" => array:6 [
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                            3 => "T&#46; Beyna"
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