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"documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2018;151:44" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image in medicine</span>" "titulo" => "“Mojito's” phytophotodermatitis, the other “lime” disease" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "44" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fitofotodermatosis por «mojitos», la otra enfermedad de «lime»" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 736 "Ancho" => 1700 "Tamanyo" => 132285 ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ignacio Torres-Navarro, Eloy Condiño-Brito, Rafael Botella-Estrada" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Ignacio" "apellidos" => "Torres-Navarro" ] 1 => array:2 [ "nombre" => "Eloy" "apellidos" => "Condiño-Brito" ] 2 => array:2 [ "nombre" => "Rafael" "apellidos" => "Botella-Estrada" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775317306590" "doi" => "10.1016/j.medcli.2017.08.008" "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/S0025775317306590?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020618301943?idApp=UINPBA00004N" "url" => "/23870206/0000015100000001/v1_201807170422/S2387020618301943/v1_201807170422/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020618302018" "issn" => "23870206" "doi" => "10.1016/j.medcle.2018.05.010" "estado" => "S300" "fechaPublicacion" => "2018-07-13" "aid" => "4341" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2018;151:e1-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Short-term prognostic value of NT-proBNT in acute infection" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e1" "paginaFinal" => "e2" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valor pronóstico a corto plazo del NT-proBNT en los pacientes con infección aguda" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1300 "Ancho" => 1645 "Tamanyo" => 103728 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">30-day mortality ROC curve.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CRP: C-reactive protein; PCT: procalcitonin; NT-ProBNP: N-terminal prohormone of brain natriuretic peptide; ROC: <span class="elsevierStyleItalic">receiver operating characteristic</span>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Juan González del Castillo, Cecilia Yañez, Francisco Javier Martín-Sánchez" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Juan" "apellidos" => "González del Castillo" ] 1 => array:2 [ "nombre" => "Cecilia" "apellidos" => "Yañez" ] 2 => array:2 [ "nombre" => "Francisco Javier" "apellidos" => "Martín-Sánchez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775317308874" "doi" => "10.1016/j.medcli.2017.11.012" "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/S0025775317308874?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020618302018?idApp=UINPBA00004N" "url" => "/23870206/0000015100000001/v1_201807170422/S2387020618302018/v1_201807170422/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Usefulness of the N-terminal pro brain natriuretic peptide as short-term prognostic factor for mortality in elderly patients with infection seen in emergency departments" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e3" "paginaFinal" => "e4" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Elisa García-Tercero, Sadaf Zafar Iqbal-Mirza, Agustín Julián-Jiménez" "autores" => array:3 [ 0 => array:3 [ "nombre" => "Elisa" "apellidos" => "García-Tercero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Sadaf Zafar" "apellidos" => "Iqbal-Mirza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:4 [ "nombre" => "Agustín" "apellidos" => "Julián-Jiménez" "email" => array:1 [ 0 => "agustinj@sescam.jccm.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Geriatría, Complejo Hospitalario Universitario de Toledo, Toledo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Complejo Hospitalario Universitario de Toledo, Toledo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Urgencias, Complejo Hospitalario Universitario de Toledo, Toledo, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Rendimiento pronóstico de mortalidad a corto plazo del fragmento N-terminal del propéptido natriurético cerebral en ancianos con infección en el servicio de urgencias" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read the interesting article by García Villalba et al.,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> in relation to the predictive capacity for mortality of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with sepsis and low risk of organ lesion. In it, the authors conclude that said biomarker (BM) obtained in the first 72<span class="elsevierStyleHsp" style=""></span>h of admission in patients with low mortality risk (according to the score <span class="elsevierStyleItalic">Sepsis-related Organ Failure Assessment</span> [SOFA]) is “the best predictor of in-hospital mortality”. Statement, in our opinion, too categorical without solid scientific evidence, at least for the time being.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In addition to congratulating the authors for their results and for highlighting the relevance of adding new tools to classify the severity of the patient with sepsis and improve their vital prognosis,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> as is the case of biomarkers (BM),<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a> we agree with them that NT-proBNP should be considered as a BM with a great capacity for predicting mortality, but we would like to make some considerations.</p><p id="par0015" class="elsevierStylePara elsevierViewall">As a contribution to what was said by García Villalba et al., we would like to compare our results with theirs, from a pilot study that we have carried out with patients treated for infection in the emergency department (ED). The samples of both studies are similar: (García Villalba et al.: 174 patients with mean age 73 [SD: 16] years with 9.8% mortality during hospitalization, a SOFA of 2 [IQR 1–3] and with 25% of patients with a history of heart failure [HF]) and our study (136 patients of whom 13 died [9.6%] at 30 days, age 85 [SD: 8] years, a SOFA of 2 [IQR 1–3] and 28% with IC). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows various patient data. In 51.47% the site of infection was respiratory, in 33.8% urinary and 6% abdominal.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">On the other hand, the authors find that the best <span class="elsevierStyleItalic">receiver operating characteristic</span> (ROC) under the curve (AUC) area obtained corresponds to NT-proBNP with 0.793 (95% HF: 0.686–0.9; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) and its best cut-off point (CP)<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.330<span class="elsevierStyleHsp" style=""></span>pg/ml; whereas lactate measurement achieves the worst results (lower performance than C-reactive protein [CRP] and procalcitonin [PCT]) with 0.514 (95% HF: 0.377–0.650; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.863). These results contrast with those obtained in our study, in the first ED assessment, since lactate, as occurs in most studies<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> is shown as the best predictor of in-hospital and short-term mortality (30 days). In our case, it obtained an ROC-AUC of 0.823 (95% HF: 0.710–0.936; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) and with a CP: 3.13<span class="elsevierStyleHsp" style=""></span>mmol/l a sensitivity (Se) of 98% and a specificity (Sp) of 88%, while NT-proBNP an AUC-ROC of 0.777 (95% HF: 0.651–0.903; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001) with an optimal CP of 1253<span class="elsevierStyleHsp" style=""></span>pg/ml with Se: 76% and Sp: 70%. In our case, CRP does not obtain any prognostic performance with AUC of 0.571 (95% HF: 0.426–0.716; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.403), which also corresponds to the latest published reviews.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We believe that the difference in results is due to the difference in clinical scenarios. The measurement of lactate and NT-proBNP during the 72<span class="elsevierStyleHsp" style=""></span>h after admission determines their levels. If we assume that they have been adequately treated with electrolyte replenishment and support treatments. So, logically, the prediction of mortality should be different upon arrival. For lactate, the levels decrease along with the prediction of mortality when a good intravascular volume balance is achieved. And, on the other hand, the maintenance or elevation of NT-proBNP levels as a consequence of diverse factors (existence of acute heart failure or water overload, age, patients with reduced systolic function compared to maintained systolic function, hypertension or renal failure, among others).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In other words, in addition to the already mentioned factors, the time for obtaining the sample must be taken into account when interpreting the results.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In summary, although NT-proBNP may be a good BM to predict short-term mortality, it cannot be stated that it is the best predictor, or that it exceeds lactate, which should be measured and monitored, as recommended by all sepsis patient care guidelines. And, also, that we must always bear in mind the patient's kinetics, characteristics, clinical situation and when and how the sample is obtained (especially if an antimicrobial and electrolyte replacement therapy has been previously administered).</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: García-Tercero E, Iqbal-Mirza SZ, Julián-Jiménez A. Rendimiento pronóstico de mortalidad a corto plazo del fragmento N-terminal del propéptido natriurético cerebral en ancianos con infección en el servicio de urgencias. Med Clin (Barc). 2018;151:e3–e4.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SD: standard deviation; GCS: Glasgow coma score; NT-proBNP: N-terminal pro-brain natriuretic peptide; SBP: systolic blood pressure; qSOFA: <span class="elsevierStyleItalic">quick Sepsis-related Organ Failure Assessment</span>; SIRS: systemic inflammatory response syndrome.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Survivors at 30 days<br><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>123 (90.5%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Short-term mortality (30 days)<br><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>13 (9.5%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean age in years, (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 (7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.39 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male sex, <span class="elsevierStyleItalic">n</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 (45%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (77%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Charlson index<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>3, <span class="elsevierStyleItalic">n</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 (53%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (61%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SBP<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>90<span class="elsevierStyleHsp" style=""></span>mmHg, <span class="elsevierStyleItalic">n</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (11.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (38.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Altered consciousness (GCS<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>14), <span class="elsevierStyleItalic">n</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (31%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (84%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SIRS criteria<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>2, <span class="elsevierStyleItalic">n</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (21%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (38%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">qSOFA<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>2, <span class="elsevierStyleItalic">n</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (24%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (77%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serum lactate in mmol/l (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.63 (0.79) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.86 (1.06) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NT-proBNP in pg/ml (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.091 (6377) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13,602 (18,498) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1805613.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Some clinical, epidemiological, exploratory and laboratory characteristics according to 30-day mortality since their assessment in the emergency department.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "El fragmento N-terminal del propéptido natriurético cerebral es el mejor predictor de mortalidad intrahospitalaria en pacientes con sepsis y bajo riesgo de lesión orgánica" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. 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