Letter to the Editor
Isolated hypoglossal nerve palsy as an initial manifestation of a lung adenocarcinoma (occipital condyle syndrome)
Parálisis aislada del nervio hipogloso como manifestación inicial de un adenocarcinoma pulmonar (síndrome del cóndilo occipital)
Antonio Bustos-Merlo, Antonio Rosales-Castillo
, Jessica Ramírez Taboada
Corresponding author
Servicio de Medicina Interna, Hospital Universitario Virgen de las Nieves, Granada, Spain
Read
Not available
Timeswas read the article
Total PDF
Total HTML
Share statistics
array:24 [ "pii" => "S2387020623003959" "issn" => "23870206" "doi" => "10.1016/j.medcle.2023.05.020" "estado" => "S300" "fechaPublicacion" => "2023-10-27" "aid" => "6309" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2023" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2023;161:362-3" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0025775323003147" "issn" => "00257753" "doi" => "10.1016/j.medcli.2023.05.016" "estado" => "S300" "fechaPublicacion" => "2023-10-27" "aid" => "6309" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2023;161:362-3" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>" "titulo" => "Parálisis aislada del nervio hipogloso como manifestación inicial de un adenocarcinoma pulmonar (síndrome del cóndilo occipital)" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "362" "paginaFinal" => "363" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Isolated hypoglossal nerve palsy as an initial manifestation of a lung adenocarcinoma (occipital condyle syndrome)" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1614 "Ancho" => 2925 "Tamanyo" => 528173 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Detalle de la exploración neurológica donde se objetiva desviación de la lengua hacia la izquierda y atrofia ipsilateral. B) Corte transversal de la tomografía craneal donde se visualiza lesión osteolítica a nivel de cóndilo izquierdo (flecha).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Antonio Bustos-Merlo, Antonio Rosales-Castillo, Jessica Ramírez Taboada" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Antonio" "apellidos" => "Bustos-Merlo" ] 1 => array:2 [ "nombre" => "Antonio" "apellidos" => "Rosales-Castillo" ] 2 => array:2 [ "nombre" => "Jessica" "apellidos" => "Ramírez Taboada" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020623003959" "doi" => "10.1016/j.medcle.2023.05.020" "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/S2387020623003959?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323003147?idApp=UINPBA00004N" "url" => "/00257753/0000016100000008/v1_202310180449/S0025775323003147/v1_202310180449/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2387020623004011" "issn" => "23870206" "doi" => "10.1016/j.medcle.2023.05.023" "estado" => "S300" "fechaPublicacion" => "2023-10-27" "aid" => "6311" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2023;161:363-4" "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" => "Can ChatGPT be a new educational tool in medicine?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "363" "paginaFinal" => "364" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Puede ser ChatGPT una nueva herramienta educativa en medicina?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Yunpeng Luo, Na Hu" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Yunpeng" "apellidos" => "Luo" ] 1 => array:2 [ "nombre" => "Na" "apellidos" => "Hu" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020623004011?idApp=UINPBA00004N" "url" => "/23870206/0000016100000008/v1_202310190859/S2387020623004011/v1_202310190859/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020623003947" "issn" => "23870206" "doi" => "10.1016/j.medcle.2023.09.007" "estado" => "S300" "fechaPublicacion" => "2023-10-27" "aid" => "6307" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2023;161:361-2" "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" => "Infiltration of the central nervous system in patients with chronic lymphatic leukemia" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "361" "paginaFinal" => "362" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infiltración del sistema nervioso central en pacientes con leucemia linfática crónica" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Clara Auría Caballero, Flor Yus Cebrian, Ingrid Magnolia Parra Salinas" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Clara Auría" "apellidos" => "Caballero" ] 1 => array:2 [ "nombre" => "Flor Yus" "apellidos" => "Cebrian" ] 2 => array:2 [ "nombre" => "Ingrid Magnolia" "apellidos" => "Parra Salinas" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775323003123" "doi" => "10.1016/j.medcli.2023.05.014" "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/S0025775323003123?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020623003947?idApp=UINPBA00004N" "url" => "/23870206/0000016100000008/v1_202310190859/S2387020623003947/v1_202310190859/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Isolated hypoglossal nerve palsy as an initial manifestation of a lung adenocarcinoma (occipital condyle syndrome)" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "362" "paginaFinal" => "363" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Antonio Bustos-Merlo, Antonio Rosales-Castillo, Jessica Ramírez Taboada" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Antonio" "apellidos" => "Bustos-Merlo" ] 1 => array:4 [ "nombre" => "Antonio" "apellidos" => "Rosales-Castillo" "email" => array:1 [ 0 => "anrocas90@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "Jessica" "apellidos" => "Ramírez Taboada" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Virgen de las Nieves, Granada, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Parálisis aislada del nervio hipogloso como manifestación inicial de un adenocarcinoma pulmonar (síndrome del cóndilo occipital)" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1614 "Ancho" => 2925 "Tamanyo" => 528093 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Detail of the neurological examination showing tongue deviation to the left and ipsilateral atrophy. (B) Cross section of the cranial tomography showing an osteolytic lesion at the level of the left condyle (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Occipital condyle syndrome, described in 1981, is a rare entity characterised by occipital headache and hypoglossal nerve involvement, usually caused by local erosive lesions of metastatic aetiology.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 55-year-old male who started with headache and left hypoglossal nerve palsy and was finally diagnosed with metastatic lung adenocarcinoma.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 55-year-old man with a personal history of type 2 diabetes mellitus with good metabolic control, hypercholesterolemia and smoking (64 packs/year). The patient came to the emergency department for severe sudden onset, left hemicranial headache, accompanied by nausea and photophobia, refractory to oral analgesia. It associated ipsilateral cervical pain with exacerbation when the head was tilted to the right, intense asthenia and weight loss of 4 kg over a month. He did not report any other symptoms in the history-taking. On physical examination, the vital signs were: blood pressure (BP) 147/73 mmHg with heart rate 77 lpm. Oxygen saturation (SpO2) 95% room air and temperature 36.5  °C. Tongue deviation to the left, together with slight atrophy of the ipsilateral hemitongue (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A), with no other neurological abnormalities. No pathological lymphadenopathies were palpable and auscultation and abdominal examination were normal. Laboratory tests showed hyperglycaemia (200 mg/dL), increased lactate dehydrogenase (255 U/L; NV 10-248) and lymphopenia (white blood cells 7230 with 430 lymphocytes/μ L; NV 1000–4000). Renal function, liver profile and coagulation showed no abnormalities. A cranial computed tomography (CT) scan was performed, which identified a 32.5 mm diameter lesion of irregular margins and soft tissue density with osteolysis of the external margin of the left occipital condyle and foramen magnum (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Given the resistance of the pain despite opioid treatment, he was finally admitted to the hospital ward for symptomatic control and aetiological study. Tumour markers showed slight elevation of carcinoembryonic antigen (7.3 ng/mL) with values in the range of Cipher 21.1 and PSA. Interferon gamma release assay (IGRA) was negative. Brain magnetic resonance imaging (MRI) showed a soft tissue mass (35 × 27 mm) in the left occipital condyle of the clivus, causing bone destruction, with intermediate/slightly low signal on T1-weighted sequence, intermediate-slightly high signal on T2-weighted sequence, with weak diffusion restriction and moderate enhancement after contrast. In order to search for the primary neoplasm and a suitable biopsy site, a positron emission tomography (PET/CT) was performed, which revealed an increased metabolic uptake of pathological intensity in the lesion described (SUVmax = 7,27), together with extensive bone involvement and a hypermetabolic focus in the left pulmonary hilum (SUVmax = 4,12) as a possible primary bronchial lesion. A CT-guided core needle biopsy of the bone lesion in the right iliac crest was performed, and anatomical pathology revealed the presence lung adenocarcinoma with a PDL1 < 1% and non-mutated epidermal growth factor receptor (EGFR). The final diagnosis was occipital condyle syndrome secondary to metastasis of lung adenocarcinoma. After being presented to the tumour committee, chemotherapy with pembrolizumab, carboplatin and pemetrexed was started, together with analgesic radiotherapy of the osteolytic occipital condyle lesion (20 Gy in 5 consecutive 4 Gy/fraction), with neurological symptom improvement.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Occipital condyle syndrome was first described by Greenberg in 1981. It consists of a unilateral occipital headache that is typically exacerbated by rotation to the opposite side and may be associated with scalp hypersensitivity<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> together with involvement of the hypoglossal nerve in the form of paresis or palsy and may be associated with dysarthria and dysphagia. Most cases are secondary to metastatic lesions of a known neoplasm or as an initial manifestation of the same, so early detection and identification are essential,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> with the prostate being the most common origin.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Diagnosis is usually made by cranial MRI, with the characteristic finding of hypointense soft tissue in T1-weighted sequence in the area of the affected condyle, replacing the local fat.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The prognosis is usually quite poor due to the often-advanced stage of the underlying neoplasm, with local radiotherapy being one of the mainstays for symptomatic control,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> together with targeted antineoplastic therapy.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0025" class="elsevierStylePara elsevierViewall">Informed consent was obtained for imaging and subsequent publication.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">Unfunded.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">No conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1614 "Ancho" => 2925 "Tamanyo" => 528093 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Detail of the neurological examination showing tongue deviation to the left and ipsilateral atrophy. (B) Cross section of the cranial tomography showing an osteolytic lesion at the level of the left condyle (arrow).</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" => "Occipital condyle syndrome: the visible part of the iceberg" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Raggabi" 1 => "I. Lalya" 2 => "A. Bourazza" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.11604/pamj.2019.33.268.19280" "Revista" => array:6 [ "tituloSerie" => "Pan Afr Med J." "fecha" => "2019" "volumen" => "33" "paginaInicial" => "268" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31692804" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0923753419365068" "estado" => "S300" "issn" => "09237534" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Occipital condyle syndrome as the first manifestation of a rectal tumour" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Martín Asenjo" 1 => "J.M. Martín Guerra" 2 => "J. Galvan Fernández" 3 => "M. Martín-Luquero Ibañez" 4 => "J.M. Prieto de Paula" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.nrl.2018.04.009" "Revista" => array:6 [ "tituloSerie" => "Neurologia (Engl Ed)" "fecha" => "2020" "volumen" => "35" "paginaInicial" => "417" "paginaFinal" => "419" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30060975" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Occipital condyle syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D.J. Capobianco" 1 => "P.W. Brazis" 2 => "F.A. Rubino" 3 => "J.N. Dalton" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1526-4610.2002.02032.x" "Revista" => array:6 [ "tituloSerie" => "Headache." "fecha" => "2002" "volumen" => "42" "paginaInicial" => "142" "paginaFinal" => "146" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12005291" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Occipital condyle syndrome: a red flag for malignancy. Comprehensive literature review and new case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Rodríguez-Pardo" 1 => "M. Lara-Lara" 2 => "B.E. Sanz-Cuesta" 3 => "B. Fuentes" 4 => "E. Díez-Tejedor" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/head.13008" "Revista" => array:6 [ "tituloSerie" => "Headache." "fecha" => "2017" "volumen" => "57" "paginaInicial" => "699" "paginaFinal" => "708" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28000214" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Occipital condyle syndrome as the first symptom of a metastatic hepatocellular carcinoma. Two case reports" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S. Garcia-Madrona" 1 => "I. Corral-Corral" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Neurol." "fecha" => "2018" "volumen" => "66" "paginaInicial" => "154" "paginaFinal" => "156" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000016100000008/v1_202310190859/S2387020623003959/v1_202310190859/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/23870206/0000016100000008/v1_202310190859/S2387020623003959/v1_202310190859/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020623003959?idApp=UINPBA00004N" ]
