Scientific letter
Tracheal Diverticulum: The Role of Fibrobronchoscopy in the Diagnosis
Divertículos traqueales: el papel de la fibrobroncoscopia en el diagnóstico
Read
4241
Timeswas read the article
526
Total PDF
3715
Total HTML
Share statistics
array:23 [ "pii" => "S2659663620300102" "issn" => "26596636" "doi" => "10.1016/j.opresp.2020.03.001" "estado" => "S300" "fechaPublicacion" => "2020-07-01" "aid" => "24" "copyrightAnyo" => "2020" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Open Respir Arch. 2020;2:197-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:19 [ "pii" => "S2659663620300369" "issn" => "26596636" "doi" => "10.1016/j.opresp.2020.05.005" "estado" => "S300" "fechaPublicacion" => "2020-07-01" "aid" => "45" "copyright" => "Sociedad Española de Neumología y Cirugía Torácica (SEPAR)" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Open Respir Arch. 2020;2:199-200" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Liposarcoma of the Anterior Mediastinum Leading to Hemodynamic Compromise" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "199" "paginaFinal" => "200" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Liposarcoma de mediastino anterior que provoca deterioro hemodinámico" ] ] "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" => 2149 "Ancho" => 2500 "Tamanyo" => 542932 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Thorax CT (coronal) with intravenous contrast that shows a well limited tumor in anterior mediastinum (12<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>9<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>9<span class="elsevierStyleHsp" style=""></span>cm) with compression of the heart (black arrows) that has a hypodense cental area suggestive of fatty tissue (asterisk). (B) MRI (sagital, T1 sequence) shows a hiperintense signal in the central zone described, confirming its fatty condition (asterisk). Onset of pericardial effusion (white arrows). (C) MRI (axial, T1 sequence) shows apical and left side pericardial effusion (gray arrows). (D) Histology of the tumor with final diagnosis of liposarcoma: tumor formed by adipocytes with atypical nuclei, high proliferative index and stellate shaped lipoblasts with positive S100 protein immuno-labeling.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Casal, Mª Elena Toubes, Anxo Martínez de Alegría Alonso, Luis Valdés" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Ana" "apellidos" => "Casal" ] 1 => array:2 [ "nombre" => "Mª Elena" "apellidos" => "Toubes" ] 2 => array:2 [ "nombre" => "Anxo" "apellidos" => "Martínez de Alegría Alonso" ] 3 => array:2 [ "nombre" => "Luis" "apellidos" => "Valdés" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2659663620300369?idApp=UINPBA00004N" "url" => "/26596636/0000000200000003/v1_202009220715/S2659663620300369/v1_202009220715/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2659663620300060" "issn" => "26596636" "doi" => "10.1016/j.opresp.2020.02.003" "estado" => "S300" "fechaPublicacion" => "2020-07-01" "aid" => "20" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Open Respir Arch. 2020;2:194-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "An Inexpensive Way to Drain Malignant Effusions With Indwelling Pleural Catheters and Its Impact on Performance Status and Pleurodesis. Experience from a Tertiary Hospital in México" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "194" "paginaFinal" => "196" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Una forma económica de drenar derrames malignos usando catéteres de drenaje pleural permanentes y su impacto en el estado funcional y la pleurodesis. La experiencia de un hospital de tercer nivel en México" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Erick J. Rendón-Ramírez, Héctor Enrique Cedillo-Huerta, Perla R. Colunga-Pedraza, Erick Willhelm Renpenning-Carrasco, Roberto Mercado-Longoria, Juan Francisco González-Guerrero, José M. Porcel" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Erick J." "apellidos" => "Rendón-Ramírez" ] 1 => array:2 [ "nombre" => "Héctor Enrique" "apellidos" => "Cedillo-Huerta" ] 2 => array:2 [ "nombre" => "Perla R." "apellidos" => "Colunga-Pedraza" ] 3 => array:2 [ "nombre" => "Erick Willhelm" "apellidos" => "Renpenning-Carrasco" ] 4 => array:2 [ "nombre" => "Roberto" "apellidos" => "Mercado-Longoria" ] 5 => array:2 [ "nombre" => "Juan Francisco" "apellidos" => "González-Guerrero" ] 6 => array:2 [ "nombre" => "José M." "apellidos" => "Porcel" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2659663620300060?idApp=UINPBA00004N" "url" => "/26596636/0000000200000003/v1_202009220715/S2659663620300060/v1_202009220715/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Tracheal Diverticulum: The Role of Fibrobronchoscopy in the Diagnosis" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "197" "paginaFinal" => "198" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ana Casal, Antonio Golpe Gómez, Vanessa Riveiro Blanco, Luis Valdés" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Ana" "apellidos" => "Casal" "email" => array:1 [ 0 => "ana.casal.mourino@sergas.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Antonio" "apellidos" => "Golpe Gómez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Vanessa" "apellidos" => "Riveiro Blanco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Luis" "apellidos" => "Valdés" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Pneumology Department, Hospital Clínico Universitario, Santiago de Compostela, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Pneumology Interdisciplinary Research Group, Santiago de Compostela Health Research Institute (IDIS), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Divertículos traqueales: el papel de la fibrobroncoscopia en el diagnóstico" ] ] "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" => 896 "Ancho" => 1674 "Tamanyo" => 177370 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Parts A, B, C and D contain chest CT scans for cases 1, 2, 3 and 4, respectively. White arrows indicate the tracheal diverticulum. Parts E, F, G and H show fibrobronchoscopy scans for cases 1, 2, 3 and 4, respectively. Black arrows indicate the connection of the tracheal diverticulum with the tracheal lumen.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tracheal diverticula (TD) are benign paratracheal air holes. TD are outpouchings composed of ciliated columnar epithelia connected to the tracheal lumen. They occur on the right posterolateral aspect of the trachea (97.1%) and can be congenital (developmental defects in tracheal cartilage) or acquired (increased intraluminal pressure).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> TD are generally an incidental finding in thoracic computed tomography examinations, as most patient remain asymptomatic. Therefore, the number of publications describing TD in connection with tracheal lumen and evidenced by fibrobronchoscopy (FBC) is limited. We report a case series of TD diagnosed in our center.</p><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 1</span>: A 40-year old, non-smoker patient referred for poor progression of respiratory infection. Pulmonary function tests were normal and thorax CT scan demonstrated a TD (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). FBC showed a TD opening in the right posterolateral aspect of the trachea, with a millimetric intraluminal connection (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 2</span>: A 53 year-old never-smoker woman with a resected left breast infiltrating ductal carcinoma. The patient presented mMRC grade-2 dyspnea with obstructive spirometry and a positive bronchodilator test. Two TD were found incidentally on CT examination (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C), which were confirmed by FBC [two TD on the right posterolateral wall of the trachea connected to the tracheal lumen (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D)].</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 3</span>: An 82 year-old ex-smoker patient with suspected lung cancer whose thorax CT showed a TD (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>E). Spirometry was non-obstructive with a moderate diffusion defect. FBC confirmed the presence of a TD located on the right posterolateral aspect of the trachea connected to the trachea (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>F).</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 4</span>: A 72 year-old non-smoker woman who showed air bubbles in the right upper mediastinum consistent with TD (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>G). Only the upper diverticulum was seen to be connected to the trachea on FBC (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>H).</p><p id="par0030" class="elsevierStylePara elsevierViewall">TD are outpouchings composed of ciliated-columnar epithelia generally connected to the tracheal lumen. They can be either single or multiple, their size ranging 1–30<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5–25<span class="elsevierStyleHsp" style=""></span>mm. They are located on the right posterolateral aspect of the trachea (T1–T3) probably due to the lack of adjacent structures supporting the trachea at that level. TD can be congenital or, more frequently, acquired. <span class="elsevierStyleItalic">Congenital TD</span> originate from defective tracheal cartilage and they contain respiratory epithelia, smooth muscle and cartilage (true diverticula).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> They are smaller, accumulate respiratory secretions and are narrow-mouthed. The usual location is on the right side, 4–5<span class="elsevierStyleHsp" style=""></span>cm below the vocal cords or just above the main carina. Acquired TD arise from increased intraluminal pressure which leads to herniation of tracheal portions lacking cartilaginous rings. They are composed of ciliated-columnar epithelia without smooth muscle and cartilage (pseudo-diverticula).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> They are larger, broad-mouthed and can originate at any level (more frequently found on the posterolateral-aspect of the trachea).</p><p id="par0035" class="elsevierStylePara elsevierViewall">The prevalence of TD in an autopsy series was 1%. Yet if CT examination is performed, prevalence increases to 2–8%.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> The vast majority of patients remain asymptomatic. Therefore, TD is generally found incidentally on thorax CT examination, which also shows the location, size and thickness of diverticular walls. FBC confirms TD connection to the lumen of the trachea, which may be challenging if connection is narrow or shows a fibrous tract. In published series, TD connection was only reported in 33.8–56.1% of patients.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Symptomatic patients can show recurrent infections occassionally associated with hemoptysis, as it is the case of our patient 1. Orotracheal intubation can be challenging in these patients, and an association has been described with lung diseases such as chronic obstructive pulmonary disease, cystic fibrosis [higher prevalence (18–28%) compared to other entities] or tracheobronchomegaly (Mounier–Kuhn's disease). In contrast, conclusive evidence has not been provided supporting an association with pulmonary emphysema.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Asymptomatic TD do not require any treatment. As to symptomatic TD, there is no solid evidence supporting a specific therapeutic approach, as age, comorbidities and symptoms must be considered.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Therapeutic options include the management of clinical symptoms (mucolitics, antibiotics, physiotherapy), open surgical resection by transcervical approach, or laser endoscopy or electrocoagulation.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Early diagnosis of symptomatic TD is crucial to prevent the development of infection, as untreated symptomatic TD generally have a poorer prognosis. Some patients have been reported to develop respiratory distress requiring emergency orotracheal intubation or paratracheal abscesses requiring surgical drainage.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> The laryngeal nerve or the esophagus can be damaged as a result of surgery; therefore, surgery should be reserved for very specific cases.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary, TD are outpouchings most frequently found on the right posterolateral aspect of the trachea and are subdivided into congenital or acquired. The number of case reports describing TD connection with the tracheal lumen as seen by FBC is limited. Although patients usually are asymptomatic and will not require treatment, fair recognition of these lesions can contribute to the management of its rare complications.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 896 "Ancho" => 1674 "Tamanyo" => 177370 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Parts A, B, C and D contain chest CT scans for cases 1, 2, 3 and 4, respectively. White arrows indicate the tracheal diverticulum. Parts E, F, G and H show fibrobronchoscopy scans for cases 1, 2, 3 and 4, respectively. Black arrows indicate the connection of the tracheal diverticulum with the tracheal lumen.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tracheal diverticulum: an atypical presentation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Srivastava" 1 => "J. Guitron" 2 => "V.A. Williams" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jtcvs.2014.03.010" "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2014" "volumen" => "148" "paginaInicial" => "3244" "paginaFinal" => "3245" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24725771" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tracheal diverticulum" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Rojas" 1 => "K. Bostanci" 2 => "S. Katsenos" 3 => "H.D. Becker" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/LBR.0b013e318205990b" "Revista" => array:6 [ "tituloSerie" => "J Bronchology Interv Pulmonol" "fecha" => "2011" "volumen" => "18" "paginaInicial" => "91" "paginaFinal" => "93" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23169027" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0050" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tracheal diverticulum: a unique case with intraoperative morphologic assessment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Chennuri" 1 => "P. Dissanayake" 2 => "U.A. Patel" 3 => "G. Tarjan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Case Rep Pathol" "fecha" => "2015" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paratracheal air cysts: prevalence and relevance to pulmonary emphysema and bronchiectasis using thoracic multidetector CT" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "N. Boyaci" 1 => "D. Sen Dokumaci" 2 => "E. Karakas" 3 => "F. Yalcin" 4 => "A.G. Oney Kurnaz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5152/dir.2014.14152" "Revista" => array:6 [ "tituloSerie" => "Diagn Interv Radiol" "fecha" => "2015" "volumen" => "21" "paginaInicial" => "42" "paginaFinal" => "46" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25430529" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0060" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tracheal diverticula" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G. Gayer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Semin Ultrasound CT MRI" "fecha" => "2016" "volumen" => "37" "paginaInicial" => "190" "paginaFinal" => "195" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tracheal diverticula: a retrospective analysis of patients referred for thoracic CT" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Pace" 1 => "A. Dapoto" 2 => "A. Surace" 3 => "A. Di Giacomo" 4 => "C. Morzenti" 5 => "E. Costantini" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Medicine (Baltimore)" "fecha" => "2018" "volumen" => "97" "paginaInicial" => "39" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A rare case of an infected tracheal diverticulum requiring emergency intervention: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Akabane" 1 => "J. Kawachi" 2 => "R. Fukai" 3 => "R. Shimoyama" 4 => "H. Kashuwagi" 5 => "H. Ogino" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int Surg Case Rep" "fecha" => "2016" "volumen" => "24" "paginaInicial" => "7" "paginaFinal" => "9" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/26596636/0000000200000003/v1_202009220715/S2659663620300102/v1_202009220715/en/main.assets" "Apartado" => array:4 [ "identificador" => "85987" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Cartas científicas" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/26596636/0000000200000003/v1_202009220715/S2659663620300102/v1_202009220715/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2659663620300102?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 80 | 10 | 90 |
| 2024 September | 113 | 17 | 130 |
| 2024 August | 105 | 15 | 120 |
| 2024 July | 99 | 18 | 117 |
| 2024 June | 93 | 11 | 104 |
| 2024 May | 119 | 13 | 132 |
| 2024 April | 106 | 12 | 118 |
| 2024 March | 119 | 11 | 130 |
| 2024 February | 137 | 13 | 150 |
| 2024 January | 164 | 3 | 167 |
| 2023 December | 97 | 11 | 108 |
| 2023 November | 117 | 9 | 126 |
| 2023 October | 133 | 9 | 142 |
| 2023 September | 73 | 1 | 74 |
| 2023 August | 70 | 3 | 73 |
| 2023 July | 73 | 4 | 77 |
| 2023 June | 81 | 4 | 85 |
| 2023 May | 92 | 8 | 100 |
| 2023 April | 75 | 2 | 77 |
| 2023 March | 80 | 3 | 83 |
| 2023 February | 76 | 4 | 80 |
| 2023 January | 43 | 5 | 48 |
| 2022 December | 55 | 7 | 62 |
| 2022 November | 52 | 15 | 67 |
| 2022 October | 50 | 6 | 56 |
| 2022 September | 40 | 9 | 49 |
| 2022 August | 37 | 7 | 44 |
| 2022 July | 44 | 8 | 52 |
| 2022 June | 59 | 7 | 66 |
| 2022 May | 31 | 6 | 37 |
| 2022 April | 48 | 12 | 60 |
| 2022 March | 59 | 14 | 73 |
| 2022 February | 47 | 7 | 54 |
| 2022 January | 90 | 7 | 97 |
| 2021 December | 85 | 10 | 95 |
| 2021 November | 92 | 12 | 104 |
| 2021 October | 82 | 16 | 98 |
| 2021 September | 73 | 11 | 84 |
| 2021 August | 47 | 6 | 53 |
| 2021 July | 30 | 8 | 38 |
| 2021 June | 22 | 11 | 33 |
| 2021 May | 63 | 10 | 73 |
| 2021 April | 168 | 15 | 183 |
| 2021 March | 64 | 13 | 77 |
| 2021 February | 65 | 12 | 77 |
| 2021 January | 48 | 15 | 63 |
| 2020 December | 29 | 13 | 42 |
| 2020 November | 50 | 13 | 63 |
| 2020 October | 16 | 13 | 29 |
| 2020 September | 24 | 18 | 42 |
| 2020 August | 0 | 9 | 9 |
| 2020 July | 0 | 16 | 16 |
| 2020 June | 0 | 1 | 1 |
| 2020 May | 0 | 4 | 4 |
| 2020 April | 0 | 9 | 9 |
Show all
