Scientific letter
Immune thrombocytopenic purpura associated with inactive ulcerative colitis in chronic treatment with adalimumab
Púrpura trombocitopénica inmune asociada a colitis ulcerosa inactiva en tratamiento crónico con adalimumab
Read
1093
Timeswas read the article
323
Total PDF
770
Total HTML
Share statistics
array:24 [ "pii" => "S2444382419302494" "issn" => "24443824" "doi" => "10.1016/j.gastre.2019.07.006" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "1424" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2019" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Gastroenterol Hepatol. 2020;43:28-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2 "HTML" => 2 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0210570519301682" "issn" => "02105705" "doi" => "10.1016/j.gastrohep.2019.07.003" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "1424" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Gastroenterol Hepatol. 2020;43:28-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 52 "formatos" => array:2 [ "HTML" => 37 "PDF" => 15 ] ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta científica</span>" "titulo" => "Púrpura trombocitopénica inmune asociada a colitis ulcerosa inactiva en tratamiento crónico con adalimumab" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "28" "paginaFinal" => "29" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Immune thrombocytopenic purpura associated with inactive ulcerative colitis in chronic treatment with adalimumab" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Benito Velayos Jiménez, Rebeca Cuello García, Lourdes del Olmo Martínez, Ana Macho Conesa, Luis Fernández Salazar" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Benito" "apellidos" => "Velayos Jiménez" ] 1 => array:2 [ "nombre" => "Rebeca" "apellidos" => "Cuello García" ] 2 => array:2 [ "nombre" => "Lourdes" "apellidos" => "del Olmo Martínez" ] 3 => array:2 [ "nombre" => "Ana" "apellidos" => "Macho Conesa" ] 4 => array:2 [ "nombre" => "Luis" "apellidos" => "Fernández Salazar" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2444382419302494" "doi" => "10.1016/j.gastre.2019.07.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382419302494?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570519301682?idApp=UINPBA00004N" "url" => "/02105705/0000004300000001/v1_202001221437/S0210570519301682/v1_202001221437/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2444382419302524" "issn" => "24443824" "doi" => "10.1016/j.gastre.2019.07.007" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "1432" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Gastroenterol Hepatol. 2020;43:30-1" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 4 "HTML" => 4 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image of the month</span>" "titulo" => "Giant sigmoid diverticulum" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "30" "paginaFinal" => "31" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Divertículo gigante de sigma" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 648 "Ancho" => 755 "Tamanyo" => 69638 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional CT.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Mikel Fiallegas Cano, Irene Moraleja Yudego, Blanca Sampedro Andrada, Leticia de Castro Santos, Itxaso Jiménez Iragorri, Noelia Martín Vicente, Jose Luis Cabriada Nuno" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Mikel" "apellidos" => "Fiallegas Cano" ] 1 => array:2 [ "nombre" => "Irene" "apellidos" => "Moraleja Yudego" ] 2 => array:2 [ "nombre" => "Blanca" "apellidos" => "Sampedro Andrada" ] 3 => array:2 [ "nombre" => "Leticia" "apellidos" => "de Castro Santos" ] 4 => array:2 [ "nombre" => "Itxaso" "apellidos" => "Jiménez Iragorri" ] 5 => array:2 [ "nombre" => "Noelia" "apellidos" => "Martín Vicente" ] 6 => array:2 [ "nombre" => "Jose Luis" "apellidos" => "Cabriada Nuno" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210570519301761" "doi" => "10.1016/j.gastrohep.2019.07.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570519301761?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382419302524?idApp=UINPBA00004N" "url" => "/24443824/0000004300000001/v1_202001221445/S2444382419302524/v1_202001221445/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2444382419302500" "issn" => "24443824" "doi" => "10.1016/j.gastre.2019.06.009" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "1425" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Gastroenterol Hepatol. 2020;43:27-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1 "HTML" => 1 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Colonic endometriosis mimicking a caecal carcinoid tumour" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "27" "paginaFinal" => "28" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Endometriosis colónica que simula tumor carcinoide cecal" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 669 "Ancho" => 1500 "Tamanyo" => 97317 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Image of endometriosis mimicking carcinoid lesion in the caecum. Cross-sectional and coronal section of the double-contrast CT scan where a lobular lesion was identified in the caecum adjacent to the ileocaecal valve of approximately 27<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>21<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm, suggestive of carcinoid tumour lesion. The green arrow is pointing to the lesion.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Javier Gómez Sánchez, Marisol Zurita Saavedra, Cristina Gonzalez Puga, Javier Gutierrez Sainz, Benito Mirón Pozo" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Javier" "apellidos" => "Gómez Sánchez" ] 1 => array:2 [ "nombre" => "Marisol" "apellidos" => "Zurita Saavedra" ] 2 => array:2 [ "nombre" => "Cristina" "apellidos" => "Gonzalez Puga" ] 3 => array:2 [ "nombre" => "Javier" "apellidos" => "Gutierrez Sainz" ] 4 => array:2 [ "nombre" => "Benito" "apellidos" => "Mirón Pozo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210570519301694" "doi" => "10.1016/j.gastrohep.2019.06.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570519301694?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382419302500?idApp=UINPBA00004N" "url" => "/24443824/0000004300000001/v1_202001221445/S2444382419302500/v1_202001221445/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Immune thrombocytopenic purpura associated with inactive ulcerative colitis in chronic treatment with adalimumab" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "28" "paginaFinal" => "29" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Benito Velayos Jiménez, Rebeca Cuello García, Lourdes del Olmo Martínez, Ana Macho Conesa, Luis Fernández Salazar" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Benito" "apellidos" => "Velayos Jiménez" "email" => array:1 [ 0 => "benitovelayos@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Rebeca" "apellidos" => "Cuello García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Lourdes" "apellidos" => "del Olmo Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Ana" "apellidos" => "Macho Conesa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Luis" "apellidos" => "Fernández Salazar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Aparato Digestivo, Hospital Clínico de Valladolid, Valladolid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Hematología, Hospital Clínico de Valladolid, Valladolid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Púrpura trombocitopénica inmune asociada a colitis ulcerosa inactiva en tratamiento crónico con adalimumab" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the letter published in your journal from Brunet et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> As the authors comment, immune thrombocytopenic purpura (ITP) is a rare haematological extra-intestinal manifestation in inflammatory bowel disease (IBD). We present the case of a female patient with a history of ulcerative colitis for many years who developed ITP despite long-term treatment with adalimumab and no gastrointestinal activity. This seems to be a particularly exceptional case and makes us reflect on the different aetiopathogenic mechanisms involved in the condition.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This was a 54-year-old woman diagnosed with left-sided ulcerative colitis in 2006. Over the course of her disease, she had been treated with mesalazine and azathioprine from 2012, with an admission in 2013 due to a severe flare-up, with no response to infliximab, but which did resolve with adalimumab at the usual dose, being increased to 40 mg weekly in autumn 2014 due to clinical activity. In December 2016, the patient was asymptomatic with complete blood count normal. In January 2017, she was admitted with rectal bleeding without diarrhoea but with anaemia, with haemoglobin levels of 7.7 g/dl and platelets 4000/µl. Her spleen appeared normal on ultrasound. Haematology completed investigations of acute thrombocytopenia with a final diagnosis of ITP and she started treatment with platelet transfusion, gamma globulin 1 g/kg/day for two days and prednisone 1 mg/kg/day, in tapering regimen for two months, during which time the patient's platelet levels returned to normal. The test for <span class="elsevierStyleItalic">Helicobacter pylori</span> was negative, as were the viral and autoimmunity determinations. A full colonoscopy was performed, showing no signs of activity, but rectal angiodysplasia, which was treated with argon. Azathioprine and adalimumab were discontinued. However, due to clinical-endoscopic flare-up when the patient stopped prednisone, it was decided to reintroduce them once again. Since then she has remained asymptomatic and with normal platelet count.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The incidence of ITP in patients already diagnosed with IBD is 12.5/100,000 population/year, apparently in relation to the severity of the gastrointestinal disease. The prevailing aetiological hypothesis is an increase in the permeability of the mucosa due to inflammation, with the passage of bacterial antigens into the circulation giving rise to a secondary, systemic, Th1 humoral response.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It has been suggested that there may be antigenic mimicry between some platelet surface proteins and bacterial glycoproteins, resulting in a cross-reactive immune response. Another mechanism could be the sequestration and subsequent direct destruction of platelets in the increased microvascularisation of the colon, which could explain the lack of antibodies, the resistance to corticosteroids and the resolving of the problem with colectomy found in some cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> These two theories would explain why ITP occurs more frequently during a flare-up of IBD. However, in our patient, the ITP developed suddenly and while her IBD was inactive.</p><p id="par0020" class="elsevierStylePara elsevierViewall">This situation led us to consider a possible relationship between the onset of her ITP and her baseline medication, despite the lack of recent changes. Although the azathioprine and mesalazine she was taking can cause thrombocytopenia due to bone-marrow toxicity, it was classified as peripheral by Haematology. Severe adalimumab-induced thrombocytopenia is recognised as anecdotal and mostly in patients taking it for disorders other than IBD<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>; an incidence of 0.1 % for events with < 100,000 platelets is reported for adalimumab.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The onset of thrombocytopenia after being on adalimumab for over two years and its non-recurrence in controlled reintroduction would go against the likelihood of drug-related aetiology in our patient.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Other authors support the existence of a genetic relationship between IBD and ITP through the major histocompatibility complex, as the incidence of ITP in patients with IBD is higher than in the general population and is accepted as not being fortuitous. Polymorphisms have been described in genes encoding immunity which could be shared between ITP and IBD.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, ITP is a very rare condition which can be associated with IBD. We have presented a case of such an association with highly unusual characteristics, including the fact that it occurred despite a lack of gastrointestinal activity and the patient being on treatment with adalimumab, and the fact that it did not recur after reintroducing adalimumab. These circumstances expose the lack of accurate data on the ultimate pathogenic mechanism by which both disorders associate and interrelate.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Velayos Jiménez B, Cuello García R, del Olmo Martínez L, Macho Conesa A, Fernández Salazar L. Púrpura trombocitopénica inmune asociada a colitis ulcerosa inactiva en tratamiento crónico con adalimumab. Gastroenterol Hepatol. 2020;43:28–29.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Púrpura trombocitopénica inmune asociada a enfermedad de Crohn con respuesta completa a infliximab" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Brunet" 1 => "M. Martínez de Sola" 2 => "P. García-Iglesias" 3 => "X. Calvet" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.gastrohep.2018.01.011" "Revista" => array:6 [ "tituloSerie" => "Gastroenterol Hepatol." "fecha" => "2019" "volumen" => "42" "paginaInicial" => "37" "paginaFinal" => "38" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29525291" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Immune thrombocytopenic purpura in ulcerative colitis: a case report and systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Chandra" 1 => "S. Finn" 2 => "E. Obah" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3402/jchimp.v4.23386" "Revista" => array:4 [ "tituloSerie" => "J Community Hosp Intern Med Perspect." "fecha" => "2014" "volumen" => "14" "paginaInicial" => "4" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Review article: non-malignant haematological complications of anti-tumour necrosis factor alpha therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T. Bessissow" 1 => "M. Renard" 2 => "I. Hoffman" 3 => "S. Vermeire" 4 => "P. Rutgeerts" 5 => "G. Van Assche" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2036.2012.05189.x" "Revista" => array:6 [ "tituloSerie" => "Aliment Pharmacol Ther." "fecha" => "2012" "volumen" => "36" "paginaInicial" => "312" "paginaFinal" => "323" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22725726" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Immune-mediated adalimumab-induced thrombocytopenia for the treatment of ulcerative colitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Lee" 1 => "M. Chary" 2 => "I. Salehi" 3 => "R. Bansal" ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Pharm Pharmaceut Sci" "fecha" => "2015" "volumen" => "7" "paginaInicial" => "456" "paginaFinal" => "458" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "https://innovareacademics.in/journals/index.php/ijpps/article/view/5351" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The cytokine polymorphisms affecting Th1/Th2 increase the susceptibility to, and severity of, chronic ITP" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. Takahashi" 1 => "T. Saitoh" 2 => "N. Gotoh" 3 => "Y. Nitta" 4 => "L. Alkebsi" 5 => "T. Kasamatsu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s12865-017-0210-3" "Revista" => array:5 [ "tituloSerie" => "BMC Immunol." "fecha" => "2017" "volumen" => "18" "paginaInicial" => "26" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28511637" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/24443824/0000004300000001/v1_202001221445/S2444382419302494/v1_202001221445/en/main.assets" "Apartado" => array:4 [ "identificador" => "77930" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letter" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24443824/0000004300000001/v1_202001221445/S2444382419302494/v1_202001221445/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382419302494?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 0 | 2 |
| 2024 October | 19 | 10 | 29 |
| 2024 September | 15 | 11 | 26 |
| 2024 August | 23 | 13 | 36 |
| 2024 July | 12 | 6 | 18 |
| 2024 June | 14 | 4 | 18 |
| 2024 May | 13 | 26 | 39 |
| 2024 April | 19 | 28 | 47 |
| 2024 March | 22 | 10 | 32 |
| 2024 February | 15 | 4 | 19 |
| 2024 January | 16 | 2 | 18 |
| 2023 December | 37 | 3 | 40 |
| 2023 November | 17 | 13 | 30 |
| 2023 October | 20 | 20 | 40 |
| 2023 September | 9 | 2 | 11 |
| 2023 August | 11 | 10 | 21 |
| 2023 July | 22 | 10 | 32 |
| 2023 June | 29 | 3 | 32 |
| 2023 May | 55 | 6 | 61 |
| 2023 April | 30 | 6 | 36 |
| 2023 March | 39 | 5 | 44 |
| 2023 February | 16 | 1 | 17 |
| 2023 January | 15 | 9 | 24 |
| 2022 December | 13 | 6 | 19 |
| 2022 November | 17 | 8 | 25 |
| 2022 October | 16 | 14 | 30 |
| 2022 September | 16 | 5 | 21 |
| 2022 August | 24 | 12 | 36 |
| 2022 July | 15 | 10 | 25 |
| 2022 June | 16 | 8 | 24 |
| 2022 May | 20 | 17 | 37 |
| 2022 April | 23 | 10 | 33 |
| 2022 March | 16 | 13 | 29 |
| 2022 February | 22 | 6 | 28 |
| 2022 January | 33 | 6 | 39 |
| 2021 December | 1 | 0 | 1 |
| 2021 November | 4 | 0 | 4 |
| 2021 October | 4 | 0 | 4 |
| 2021 September | 5 | 0 | 5 |
| 2021 August | 3 | 0 | 3 |
| 2021 July | 1 | 0 | 1 |
| 2021 June | 2 | 0 | 2 |
| 2021 May | 1 | 0 | 1 |
| 2021 April | 2 | 0 | 2 |
| 2021 March | 8 | 0 | 8 |
| 2021 February | 5 | 0 | 5 |
| 2021 January | 3 | 2 | 5 |
| 2020 December | 1 | 0 | 1 |
| 2020 November | 2 | 1 | 3 |
| 2020 October | 1 | 1 | 2 |
| 2020 September | 5 | 0 | 5 |
| 2020 July | 2 | 0 | 2 |
| 2020 June | 3 | 0 | 3 |
| 2020 May | 2 | 0 | 2 |
| 2020 April | 2 | 0 | 2 |
| 2020 March | 10 | 2 | 12 |
| 2020 January | 2 | 0 | 2 |
Show all
