Letter to the Director
COVID-19 associated pulmonary aspergillosis: New consensus criteria for diagnosis
Aspergilosis pulmonar asociada a COVID-19 (CAPA): nuevos consensos en criterios diagnósticos
Read
65
Timeswas read the article
1
Total PDF
64
Total HTML
Share statistics
array:24 [ "pii" => "S2341192923000458" "issn" => "23411929" "doi" => "10.1016/j.redare.2022.01.006" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1429" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2022" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2023;70:178-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0034935622000214" "issn" => "00349356" "doi" => "10.1016/j.redar.2022.01.003" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1429" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Rev Esp Anestesiol Reanim. 2023;70:178-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">CARTA AL DIRECTOR</span>" "titulo" => "Aspergilosis pulmonar asociada a COVID-19: Nuevos consensos en criterios diagnósticos" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "178" "paginaFinal" => "179" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "COVID-19 associated pulmonary aspergillosis: New consensus criteria for diagnosis" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D.A. Vergara-Maestre" "autores" => array:1 [ 0 => array:2 [ "nombre" => "D.A." "apellidos" => "Vergara-Maestre" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192923000458" "doi" => "10.1016/j.redare.2022.01.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000458?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935622000214?idApp=UINPBA00004N" "url" => "/00349356/0000007000000003/v1_202302271739/S0034935622000214/v1_202302271739/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192923000380" "issn" => "23411929" "doi" => "10.1016/j.redare.2022.01.005" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1430" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2023;70:180-2" "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 Director</span>" "titulo" => "Feasibility of prone position with a single operator for low resources ICU: Step-by-step technical description" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "180" "paginaFinal" => "182" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Viabilidad de la pronación con un único operador para la UCI con bajos recursos: descripción técnica paso a paso" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 1291 "Ancho" => 2500 "Tamanyo" => 406954 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Video with a simulated patient showing the single-operator proning procedure.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. Gemelli, G. Sotera Lic, C. Barrios, D. Pina, I. Carboni Bisso, M. Las Heras" "autores" => array:6 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "Gemelli" ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Sotera Lic" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Barrios" ] 3 => array:2 [ "nombre" => "D." "apellidos" => "Pina" ] 4 => array:2 [ "nombre" => "I." "apellidos" => "Carboni Bisso" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Las Heras" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935622000238" "doi" => "10.1016/j.redar.2022.01.004" "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/S0034935622000238?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000380?idApp=UINPBA00004N" "url" => "/23411929/0000007000000003/v1_202304111726/S2341192923000380/v1_202304111726/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192923000410" "issn" => "23411929" "doi" => "10.1016/j.redare.2021.11.008" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1414" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 0 "subdocumento" => "rev" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2023;70:169-77" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Spontaneous subcapsular hepatic hematoma in pregnant patients" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "169" "paginaFinal" => "177" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hematoma hepático subcapsular espontáneo en gestantes" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2633 "Ancho" => 2925 "Tamanyo" => 439924 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Therapeutic algorithm for SSHH during labour or caesarean section.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CCU: critical care unit; CT: computed tomography; GA: general anaesthesia; MRI: magnetic resonance imaging; PACU: post anaesthesia recovery unit; rFVII: recombinant factor VII; SSHH: spontaneous subcapsular hepatic haematoma.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Calvo, E. Monge, L. Bermejo, F. Palacio-Abizanda" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Calvo" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Monge" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Bermejo" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Palacio-Abizanda" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935621003108" "doi" => "10.1016/j.redar.2021.11.005" "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/S0034935621003108?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000410?idApp=UINPBA00004N" "url" => "/23411929/0000007000000003/v1_202304111726/S2341192923000410/v1_202304111726/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Director</span>" "titulo" => "COVID-19 associated pulmonary aspergillosis: New consensus criteria for diagnosis" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "178" "paginaFinal" => "179" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "D.A. Vergara-Maestre" "autores" => array:1 [ 0 => array:4 [ "nombre" => "D.A." "apellidos" => "Vergara-Maestre" "email" => array:1 [ 0 => "daniel.vergara.m@gmail.co" ] "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" => "ACCIG-SEDARME, Anesthesiology and Critical Care Student Society Colombia-Semillero de Anestesiología, Reanimación y Medicina de Urgencia, Facultad de Medicina, Universidad de Caldas, Manizales, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Asociación Colombiana de Microbiología, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aspergilosis pulmonar asociada a COVID-19 (CAPA): nuevos consensos en criterios diagnósticos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the article published by Sánchez Martín et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> entitled "Invasive pulmonary aspergillosis in patients with COVID-19 respiratory distress syndrome", which analyses cases with suspected COVID-19 associated pulmonary aspergillosis (CAPA). Patients underwent bronchoalveolar lavage (BAL) mycological culture as isolation methods for Aspergillus spp. The AspICU algorithm was followed to establish the diagnosis of probable invasive pulmonary aspergillosis (IPA), also considering galactomannan (GM) antigen positivity as relevant. Probable IPA was confirmed in 3 of them, who were admitted for more than 21 days for severe acute respiratory distress syndrome and received corticosteroid therapy. In addition, they consider the need for a new diagnostic algorithm that allows early treatment due to the deleterious consequences it may have in critically ill patients. We thank the authors for this valuable evidence. However, we would like to make a few comments.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Co-infection between SARS-CoV-2 and other respiratory pathogens has become another serious concern in the management of patients with COVID-19. Bacterial or viral co-infections have been reported in many studies, while fungal co-infections have also been reported. Of the latter, Aspergillus spp. requires great attention, as API is difficult to diagnose in these patients. Co-infection rates have been found in countries such as China at 23.3%, in Belgium at 20.6% and in the Netherlands at 19.6% related to a high morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Some authors have already developed consensus criteria for the diagnosis and management of CAPA. Koehler et al.,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> in association with the European Confederation for Medical Mycology and the International Society for Human and Animal Mycology, formed an expert group to propose consensus criteria for a case definition of CAPA and to provide updated recommendations for diagnosis and treatment. They propose as entry criteria a positive RT-PCR for SARS-CoV-2 at any time during 2 weeks between hospital admission and ICU admission or within 72−96 h after ICU admission, associated with the development of CAPA in the following weeks.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Proven CAPA is defined as pulmonary or tracheobronchial infection confirmed by direct histopathological or microscopic detection, or both, of fungal elements morphologically consistent with Aspergillus spp, showing invasive growth in tissues with associated tissue damage, or Aspergillus spp. recovered by culture or detected by microscopy, histology studies or PCR from material obtained by sterile aspiration or biopsy from a pulmonary site, showing infectious disease.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis of probable tracheobronchial CAPA requires the observation of tracheobronchial ulceration, nodule, pseudomembrane, plaque or eschar, alone or in combination, on bronchoscopic examination and mycological evidence (microscopic detection of fungal elements in BAL; positive BAL culture or PCR; serum GM index >.5 or serum lateral flow assay (LFA) index >5; or BAL GM index ≥1.0 or BAL LFA index ≥1.0). Tracheobronchitis can be defined only by visualisation of the tracheal system by bronchoscopy.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnosis of probable pulmonary CAPA requires a pulmonary infiltrate or nodules, preferably documented by computed tomography (CT) of the chest, or cavitating infiltrate (not attributed to another cause), or both, combined with mycological evidence (microscopic detection of fungal elements in BAL; positive BAL culture; serum GM index >.5 or serum EFL index >.5; BAL GM index ≥1.0 or BAL EFL index ≥1.0; 2 or more positive PCR tests for Aspergillus spp. in plasma, serum or whole blood; a single positive PCR test for Aspergillus spp. in BAL fluid (<36 cycles); or a single positive PCR test for Aspergillus spp. in plasma, serum or whole blood, and a single positive test in BAL fluid (any number of cycles is allowed as a threshold).</p><p id="par0035" class="elsevierStylePara elsevierViewall">Diagnosis of possible pulmonary CAPA requires pulmonary infiltrate or nodules, preferably documented by chest CT, or cavitating infiltrate (not attributed to another cause) in combination with mycological evidence (microscopic detection of fungal elements in a non-bronchoscopic lavage (LNB); positive LNB culture; single LNB GM index >4.5; LNB GM index >1.2 2 times or more or LNB GM index >1.2 plus another positive LNB mycology test (LNB PCR or EFL).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Hashim et al.,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> propose new criteria in the form of practice guidelines for the diagnosis of CAPA. They define a suspected case of CAPA as a SARS-CoV-2 positive patient with the presence of clinical risk factors (refractory fever, pleural rub, chest pain, haemoptysis, respiratory failure and respiratory distress syndrome), respiratory failure and acute respiratory distress syndrome) and abnormal CT findings (nodules with cavities and dendritic sign, inverse halo sign, nodular consolidation, cobblestone pattern, nodular infiltrates, air crescent sign, pleural effusion and some indeterminate and atypical signs).</p><p id="par0045" class="elsevierStylePara elsevierViewall">A possible case of CAPA is defined as a suspicion of CAPA (i.e., presence of clinical risk factors and abnormal CT findings) with a positive GM or mannoprotein (MP) in BAL, LNB or serum as mycological evidence of Aspergillus spp. infection.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A probable case of CAPA is defined as the presence of clinical risk factors, abnormal CT findings, GM or MP biomarker positivity in BAL, LNB or serum and direct microscopy or Asp-PCR (preferably multiplex) detecting Aspergillus spp. in BAL, LNB or blood samples.</p><p id="par0055" class="elsevierStylePara elsevierViewall">These guidelines facilitate clinical decision-making. For a suspected case, further studies are required to consider antifungal treatment, a possible case can be considered for empirical antifungal treatment and a probable case requires targeted antifungal treatment.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The current exponential growth of COVID-19 cases is also associated with an increase in CAPA cases, so it is necessary to take into account the established consensus in order to allow early diagnosis and timely treatment with the aim of reducing the high morbidity and mortality associated with this clinical entity.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">This study did not receive any type of funding.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aspergilosis pulmonar invasiva en pacientes con síndrome de distrés respiratorio por COVID-19 [Invasive pulmonary aspergillosis in patients with acute respiratory syndrome by COVID-19]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C. Sánchez Martín" 1 => "E. Madrid Martínez" 2 => "R. González Pellicer" 3 => "R. Armero Ibáñez" 4 => "E. Martínez González" 5 => "J.V. Llau Pitarch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2021.02.012" "Revista" => array:7 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2022" "volumen" => "69" "numero" => "1" "paginaInicial" => "48" "paginaFinal" => "53" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33994593" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "COVID-19 associated with pulmonary aspergillosis: A literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.C. Lai" 1 => "W.L. Yu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jmii.2020.09.004" "Revista" => array:7 [ "tituloSerie" => "J Microbiol Immunol Infect" "fecha" => "2021" "volumen" => "54" "numero" => "1" "paginaInicial" => "46" "paginaFinal" => "53" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33012653" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Koehler" 1 => "M. Bassetti" 2 => "A. Chakrabarti" 3 => "S. Chen" 4 => "A.L. Colombo" 5 => "M. Hoenigl" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1473-3099(20)30847-1" "Revista" => array:7 [ "tituloSerie" => "Lancet Infect Dis" "fecha" => "2021" "volumen" => "21" "numero" => "6" "paginaInicial" => "e149" "paginaFinal" => "e162" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33333012" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Practice guidelines for the diagnosis of COVID-19-associated pulmonary aspergillosis in an intensive care setting" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Z. Hashim" 1 => "Z. Neyaz" 2 => "R. Marak" 3 => "A. Nath" 4 => "S. Nityanand" 5 => "N.K. Tripathy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/08850666211047166" "Revista" => array:2 [ "tituloSerie" => "J Intensive Care Med" "fecha" => "2021" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000007000000003/v1_202304111726/S2341192923000458/v1_202304111726/en/main.assets" "Apartado" => array:4 [ "identificador" => "66474" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Director" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000007000000003/v1_202304111726/S2341192923000458/v1_202304111726/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000458?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 0 | 1 |
| 2024 October | 1 | 0 | 1 |
| 2024 September | 12 | 0 | 12 |
| 2024 August | 10 | 0 | 10 |
| 2024 July | 5 | 0 | 5 |
| 2024 June | 2 | 0 | 2 |
| 2024 May | 1 | 0 | 1 |
| 2024 April | 1 | 0 | 1 |
| 2024 March | 4 | 0 | 4 |
| 2024 February | 4 | 0 | 4 |
| 2024 January | 8 | 1 | 9 |
| 2023 December | 15 | 0 | 15 |
