metricas
covid
Buscar en
Medicina Clínica (English Edition)
Toda la web
Inicio Medicina Clínica (English Edition) Heparin-induced thrombocytopenia with aortoiliac thrombosis treated with argatro...
Journal Information

Statistics

Follow this link to access the full text of the article

Letter to the Editor
Heparin-induced thrombocytopenia with aortoiliac thrombosis treated with argatroban
Trombocitopenia inducida por heparina con trombosis aortoilíaca tratada con argatrobán
Lleimi Alarcón Péreza,
Corresponding author
jeimy.alarcon@hotmail.com

Corresponding author.
, Ana María Rodríguez Huertab, Patricia Duque Gonzáleza
a Departamento de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
b Departamento de Hematología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
Read
Not available
Times
was read the article
Total PDF
Total HTML
Share statistics
 array:24 [
  "pii" => "S2387020617301894"
  "issn" => "23870206"
  "doi" => "10.1016/j.medcle.2016.12.057"
  "estado" => "S300"
  "fechaPublicacion" => "2017-03-22"
  "aid" => "3906"
  "copyright" => "Elsevier España, S.L.U.. All rights reserved"
  "copyrightAnyo" => "2017"
  "documento" => "simple-article"
  "crossmark" => 1
  "subdocumento" => "cor"
  "cita" => "Med Clin. 2017;148:286-7"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:1 [
    "total" => 0
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0025775316307114"
      "issn" => "00257753"
      "doi" => "10.1016/j.medcli.2016.12.019"
      "estado" => "S300"
      "fechaPublicacion" => "2017-03-22"
      "aid" => "3906"
      "copyright" => "Elsevier España, S.L.U."
      "documento" => "simple-article"
      "crossmark" => 1
      "subdocumento" => "cor"
      "cita" => "Med Clin. 2017;148:286-7"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:2 [
        "total" => 448
        "formatos" => array:2 [
          "HTML" => 14
          "PDF" => 434
        ]
      ]
      "es" => array:10 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>"
        "titulo" => "Trombocitopenia inducida por heparina con trombosis aortoil&#237;aca tratada con argatrob&#225;n"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "286"
            "paginaFinal" => "287"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Heparin-induced thrombocytopenia with aortoiliac thrombosis treated with argatroban"
          ]
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Lleimi Alarc&#243;n P&#233;rez, Ana Mar&#237;a Rodr&#237;guez Huerta, Patricia Duque Gonz&#225;lez"
            "autores" => array:3 [
              0 => array:2 [
                "nombre" => "Lleimi"
                "apellidos" => "Alarc&#243;n P&#233;rez"
              ]
              1 => array:2 [
                "nombre" => "Ana Mar&#237;a"
                "apellidos" => "Rodr&#237;guez Huerta"
              ]
              2 => array:2 [
                "nombre" => "Patricia"
                "apellidos" => "Duque Gonz&#225;lez"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2387020617301894"
          "doi" => "10.1016/j.medcle.2016.12.057"
          "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/S2387020617301894?idApp=UINPBA00004N"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775316307114?idApp=UINPBA00004N"
      "url" => "/00257753/0000014800000006/v2_201706011531/S0025775316307114/v2_201706011531/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2387020617301900"
    "issn" => "23870206"
    "doi" => "10.1016/j.medcle.2016.12.058"
    "estado" => "S300"
    "fechaPublicacion" => "2017-03-22"
    "aid" => "3908"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46;"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "cor"
    "cita" => "Med Clin. 2017;148:287-8"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>"
      "titulo" => "Severe hypocalcemia due to osteoblastic metastasis of prostate cancer"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "287"
          "paginaFinal" => "288"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Hipocalcemia intensa por met&#225;stasis osteobl&#225;sticas de adenocarcinoma de pr&#243;stata"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Marta Di&#233;guez Felechosa, Julio Noval Men&#233;ndez, Laura Manj&#243;n Miguelez"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "Marta"
              "apellidos" => "Di&#233;guez Felechosa"
            ]
            1 => array:2 [
              "nombre" => "Julio"
              "apellidos" => "Noval Men&#233;ndez"
            ]
            2 => array:2 [
              "nombre" => "Laura"
              "apellidos" => "Manj&#243;n Miguelez"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0025775316307138"
        "doi" => "10.1016/j.medcli.2016.12.021"
        "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/S0025775316307138?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617301900?idApp=UINPBA00004N"
    "url" => "/23870206/0000014800000006/v1_201704120030/S2387020617301900/v1_201704120030/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S2387020617301870"
    "issn" => "23870206"
    "doi" => "10.1016/j.medcle.2017.03.012"
    "estado" => "S300"
    "fechaPublicacion" => "2017-03-22"
    "aid" => "3904"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46;"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "cor"
    "cita" => "Med Clin. 2017;148:285-6"
    "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" => "Cushing&#39;s syndrome caused by mixed adrenal tumor of cortical origin associated with myelolipoma"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "285"
          "paginaFinal" => "286"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "S&#237;ndrome de Cushing causado por un tumor suprarrenal mixto de origen cortical asociado a un mielolipoma"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Fig&#46; 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 864
              "Ancho" => 998
              "Tamanyo" => 125656
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Abdominal computed tomography scan&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Andreu Sim&#243;-Servat, Manuel P&#233;rez Maraver, Jordi Caballero Corchuelo"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "Andreu"
              "apellidos" => "Sim&#243;-Servat"
            ]
            1 => array:2 [
              "nombre" => "Manuel"
              "apellidos" => "P&#233;rez Maraver"
            ]
            2 => array:2 [
              "nombre" => "Jordi"
              "apellidos" => "Caballero Corchuelo"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0025775316307096"
        "doi" => "10.1016/j.medcli.2016.12.017"
        "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/S0025775316307096?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617301870?idApp=UINPBA00004N"
    "url" => "/23870206/0000014800000006/v1_201704120030/S2387020617301870/v1_201704120030/en/main.assets"
  ]
  "en" => array:13 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>"
    "titulo" => "Heparin-induced thrombocytopenia with aortoiliac thrombosis treated with argatroban"
    "tieneTextoCompleto" => true
    "saludo" => "Dear Editor&#44;"
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "286"
        "paginaFinal" => "287"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Lleimi Alarc&#243;n P&#233;rez, Ana Mar&#237;a Rodr&#237;guez Huerta, Patricia Duque Gonz&#225;lez"
        "autores" => array:3 [
          0 => array:4 [
            "nombre" => "Lleimi"
            "apellidos" => "Alarc&#243;n P&#233;rez"
            "email" => array:1 [
              0 => "jeimy&#46;alarcon&#64;hotmail&#46;com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Ana Mar&#237;a"
            "apellidos" => "Rodr&#237;guez Huerta"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Patricia"
            "apellidos" => "Duque Gonz&#225;lez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Departamento de Anestesiolog&#237;a y Reanimaci&#243;n&#44; Hospital General Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Departamento de Hematolog&#237;a&#44; Hospital General Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Trombocitopenia inducida por heparina con trombosis aortoil&#237;aca tratada con argatrob&#225;n"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Heparin-induced thrombocytopenia &#40;HIT&#41; is an acquired and transient prothrombotic disorder&#44; defined by a decrease in platelet count &#40;&#8805;50&#37; of baseline value&#41; of immune mechanism caused by the administration of unfractionated heparin &#40;UFH&#41; and&#44; less frequently&#44; the administration of low molecular weight heparin&#46; It presents an overall incidence of 0&#46;2&#8211;5&#37;&#44; although it is variable and depends on the type of heparin&#44; prior heparin exposure and the administration context&#46; HIT is caused by the formation of IgG antibodies against the heparin&#47;platelet factor 4 &#40;PF4&#41; antigenic complex&#44; resulting in platelet activation and thrombin generation&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a man who developed thrombocytopenia after 7 days of treatment with UFH&#44; associating aortoiliac thrombosis which was treated with argatroban&#44; confirming the presence of antiheparin&#47;PF4 antibodies&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of a 62-year-old male with a history of hypertension&#44; dyslipidaemia&#44; obesity&#44; atrial flutter treated with ablation&#44; ex-smoker and COPD&#46; A femorofemoral <span class="elsevierStyleItalic">bypass</span> was performed from right to left due to a grade <span class="elsevierStyleSmallCaps">ii</span>b chronic ischemia of the left lower limb &#40;LLL&#41; with occlusion of the left iliac axis&#46; It required immediate thrombectomy and <span class="elsevierStyleItalic">bypass</span> reimplantation due to LLL ischemia&#46; The clinical course during his stay in postoperative care was torpid&#46; The following conditions stood out as main complications&#58; LLL compartment syndrome&#44; requiring fasciotomy&#44; respiratory distress syndrome secondary to septic <span class="elsevierStyleItalic">shock</span>&#44; oligoanuric multifactorial renal failure requiring continuous veno-venous hemofiltration&#44; and cardiovascular dysfunction with arrhythmias treated with electrical cardioversion&#46; In the ninth postoperative day&#44; the patient developed cyanosis and lividity of the operated limb&#44; detecting on the emergency CT angiography a massive thrombosis from the infrarenal aorta to the iliofemoral axis of the operated limb&#46; UFH infusion was maintained for anticoagulant range right from the immediate postoperative period&#44; observing a progressive decrease in platelet count&#44; from 177<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L on the sixth postoperative day to 28<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L at that time&#46; Given the context of UFH infusion 7 days before the decrease in platelets&#44; a history of major vascular surgery and the new massive acute thrombotic episode&#44; the diagnosis of HIT was suspected with a <span class="elsevierStyleItalic">4T Score</span> &#40;Thrombocytopenia<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Thrombosis<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Time relative to the use of heparin<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Other causes of thrombocytopenia&#41; of high probability&#46; UFH infusion was immediately suspended and detection of antiheparin&#47;PF4 antibodies was requested&#46; An emergency axillobifemoral <span class="elsevierStyleItalic">bypass</span> was performed with argatroban 1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min due to intraoperative thrombosis&#44; with coagulation controls through lab tests and thromboelastometry &#40;ROTEM&#41;&#46; In ROTEM&#44; a prolonged clotting time of EXTEM and INTEM was observed&#44; without HEPTEM correction &#40;discarding a residual effect of UFH&#41;&#44; and a decrease in maximum clot amplitude&#44; alterations possibly due to thrombocytopenia&#44; decrease hepatic synthesis factors and argatroban&#46; Lab results confirmed a thrombocytopenia of 47<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#44; INR 5&#46;4&#44; APTT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>120 and fibrinogen impossible to calculate&#44; so argatroban infusion was suspended&#46; Despite this hypocoagulability situation maintained for 24<span class="elsevierStyleHsp" style=""></span>h&#44; possibly due to consumption and impaired synthesis coagulopathy&#44; the patient presented a new episode of thrombosis requiring thrombectomy&#46; He died hours later from multiple organ failure&#46; Lab results confirmed the presence of antiheparin&#47;PF4 antibodies by ELISA&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This case reflects the severity of HIT and the importance of early diagnosis and treatment&#46; The diagnosis is clinical in cases of thrombocytopenia after heparin administration&#46; Laboratory diagnosis based on demonstrating the presence of antiheparin&#47;PF4 antibodies&#44; helps to confirm the clinical diagnosis and should not delay treatment&#46; Heparin must be suspended immediately&#44; establishing an alternative anticoagulant therapy to prevent or treat thromboembolic complications&#44; with thrombin inhibitors being the indicated drugs&#58; lepidurin&#44; bivalirudin and argatroban&#46; The latter&#44; has a short half-life&#44; hepatic metabolism and biliary elimination&#46; The safety and efficacy of thrombosis treatment due to HIT with argatroban has been demonstrated in 2 prospective studies&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">2</span></a> Its monitoring is conducted through APTT&#44; but its effects are also evident using ROTEM&#46; However&#44; no studies are yet available on ROTEM monitoring regarding coagulation disorders caused by the administration of thrombin inhibitors&#46;</p></span>"
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Alarc&#243;n P&#233;rez L&#44; Rodr&#237;guez Huerta AM&#44; Duque Gonz&#225;lez P&#46; Trombocitopenia inducida por heparina con trombosis aortoil&#237;aca tratada con argatrob&#225;n&#46; Med Clin &#40;Barc&#41;&#46; 2017&#59;148&#58;286&#8211;287&#46;</p>"
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:2 [
            0 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Trombocitopenia inducida por heparina"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "I&#46; Cruz-Gonz&#225;lez"
                            1 => "M&#46; S&#225;nchez-Ledesma"
                            2 => "P&#46;L&#46; S&#225;nchez"
                            3 => "I&#46;K&#46; Jang"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Cardiol"
                        "fecha" => "2007"
                        "volumen" => "60"
                        "paginaInicial" => "1071"
                        "paginaFinal" => "1082"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17953929"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The direct thrombin inhibitor argatroban&#58; a review of its use in patients with and without HIT"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Koster"
                            1 => "K&#46;G&#46; Fischer"
                            2 => "S&#46; Harder"
                            3 => "F&#46; Mertzlufft"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Biologics"
                        "fecha" => "2007"
                        "volumen" => "1"
                        "paginaInicial" => "105"
                        "paginaFinal" => "112"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19707320"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/23870206/0000014800000006/v1_201704120030/S2387020617301894/v1_201704120030/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "43309"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Letters to the Editor"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014800000006/v1_201704120030/S2387020617301894/v1_201704120030/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617301894?idApp=UINPBA00004N"
]
Article information
ISSN: 23870206
Original language: English
The statistics are updated each day

Follow this link to access the full text of the article

es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos