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Análisis de recursos asistenciales para el ictus en España en 2012: ¿beneficios de la Estrategia del Ictus del Sistema Nacional de Salud?
Analysis of stroke care resources in Spain in 2012: Have we benefitted from the Spanish Health System's stroke care strategy?
J.C. López Fernándeza,
Autor para correspondencia
jclopezfdez@gmail.com

Autor para correspondencia.
, J. Masjuan Vallejob, J. Arenillas Larac, M. Blanco Gonzálezd, E. Botia Paniaguae, I. Casado Naranjof, E. Deyá Arbonag, B. Escribano Sorianoh, M.M. Freijo Guerreroi, B. Fuentesj, J. Gállego Cullerek, D. Geffners Sclarskyil, A. Gil Núñezm, C. Gómez Escalonillan, A. Lago Martino, I. Legarda Ramírezp, J.L. Maciñeiras Monteroq, J. Maestre Morenor, F. Moniche Álvarezs, R. Muñoz Arrondok..., F. Purroy Garcíat, J.M. Ramírez Morenou, M. Rebollo Álvarez Amandixv, J. Roquerw, F. Rubio Borregox, T. Seguray, M. Serrano Ponzaz, J. Tejada GarcíaA, C. Tejero JusteB, J.A. Vidal SánchezCVer más
a Servicio de Neurología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España
b Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, España
c Servicio de Neurología, Hospital Clínico de Valladolid, Valladolid, España
d Servicio de Neurología, Hospital Clínico de Santiago, Coruña, España
e Sección de Neurología, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, España
f Servicio de Neurología, Hospital San Pedro de Alcántara, Cáceres, España
g Servicio de Neurología, Hospital de Manacor, Manacor, Mallorca, España
h Servicio de Neurología, Hospital Virgen de la Arrixaca, Murcia, España
i Servicio de Neurología, Hospital de Basurto, Bilbao, Vizcaya, España
j Servicio de Neurología y Centro de Ictus, Hospital Universitario La Paz, Instituto de Investigación IdiPAZ, Universidad Autónoma de Madrid, Madrid, España
k Servicio de Neurología, Hospital de Navarra, Pamplona, Navarra, España
l Servicio de Neurología, Hospital General de Castellón, Castellón, España
m Servicio de Neurología, Hospital Gregorio Marañón, Madrid, España
n Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España
o Servicio de Neurología, Hospital Universitari La Fe, Valencia, España
p Servicio de Neurología, Hospital Son Espases, Palma de Mallorca, Mallorca, España
q Servicio de Neurología, Hospital Mexoeiro, Vigo, Pontevedra, España
r Servicio de Neurología, Hospital Virgen de las Nieves, Granada, España
s Servicio de Neurología, Hospital Virgen del Rocío, Sevilla, España
t Servicio de Neurología, Hospital Arnau de Vilanova, Lleida, España
u Servicio de Neurología, Hospital Infanta Cristina, Badajoz, España
v Servicio de Neurología, Hospital Marqués de Valdecilla, Santander, España
w Servicio de Neurología, Hospital del Mar, Barcelona, España
x Servicio de Neurología, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, España
y Servicio de Neurología, Hospital General de Albacete, Albacete, España
z Servicio de Neurología, Hospital San Pedro, Logroño, España
A Servicio de Neurología, Complejo Hospitalario de León, León, España
B Servicio de Neurología, Hospital Clínico Universitario, Zaragoza, España
C Sección de Neurología, Hospital Valle del Nalón, Langreo, Asturias, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">El ictus es una entidad compleja y heterog&#233;nea que incluye tanto la enfermedad cerebrovascular isqu&#233;mica como la hemorr&#225;gica&#46; El ictus desde el punto de vista etiol&#243;gico se relaciona fundamentalmente con los factores de riesgo vascular tradicionales&#59; asoci&#225;ndose con frecuencia a las otras manifestaciones de la enfermedad vascular ateroscler&#243;tica como son la cardiopat&#237;a isqu&#233;mica y la enfermedad arterial perif&#233;rica&#46; Constituye en la actualidad una importante causa de dependencia y muerte<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#44; adem&#225;s de representar un importante coste personal&#44; familiar y social<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El proceso asistencial al ictus ha experimentado una mejor&#237;a dr&#225;stica tras la implantaci&#243;n de las Unidades de Ictus &#40;UI&#41;&#46; Las UI se organizan como una unidad de cuidados intermedios durante la fase aguda y representan una intervenci&#243;n coste-efectiva al disminuir la mortalidad&#44; las secuelas neurol&#243;gicas y la necesidad de institucionalizaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a>&#46; Este efecto beneficioso de las UI es independiente de la edad&#44; sexo&#44; subtipo etiol&#243;gico y la gravedad del ictus<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; La trombolisis intravenosa es la segunda medida terap&#233;utica que es capaz de mejorar el pron&#243;stico funcional del paciente<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a>&#44; aunque requiere de neur&#243;logos entrenados en la asistencia a pacientes con ictus en fase aguda&#44; para garantizar su uso seguro y la indicaci&#243;n adecuada<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a>&#46; En pacientes que no se han beneficiado de la trombolisis intravenosa o en aquellos en los que est&#225; contraindicada&#44; se puede recurrir a las t&#233;cnicas endovasculares &#40;intervencionismo neurovascular &#91;INV&#93;&#41; mediante la trombolisis intrarterial o mediante trombectom&#237;a mec&#225;nica<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Los estudios de &#171;neuroimagen avanzada&#187; mediante la tomograf&#237;a computarizada &#40;TC&#41; o la resonancia magn&#233;tica &#40;RM&#41; permiten valorar el tejido cerebral en riesgo&#44; lo que es &#250;til en la toma de decisiones para el tratamiento trombol&#237;tico en supuestos como el ictus del despertar o para ampliar la ventana terap&#233;utica<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;13</span></a>&#46; La telemedicina es un recurso que permite valorar a distancia a los pacientes y as&#237; favorecer el acceso al tratamiento trombol&#237;tico en aquellos pacientes en que lo tienen limitado por razones geogr&#225;ficas<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a>&#46; De esta manera se puede valorar tanto el examen cl&#237;nico del paciente como los estudios radiol&#243;gicos realizados <span class="elsevierStyleItalic">in situ</span>&#46; Finalmente&#44; otra intervenci&#243;n que ha demostrado beneficio en la asistencia al ictus es el empleo de la craniectom&#237;a descompresiva en el tratamiento del infarto maligno de la cerebral media&#44; entidad en la que se ha conseguido reducir la alta mortalidad y la discapacidad asociadas<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El Grupo de Estudio de Enfermedades Cerebrovasculares &#40;GEECV&#41; de la Sociedad Espa&#241;ola de Neurolog&#237;a ha establecido unas recomendaciones para la organizaci&#243;n asistencial del ictus agudo<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#8211;19</span></a>&#46; El Plan de Atenci&#243;n Sanitaria al Ictus &#40;PASI&#41; y su actualizaci&#243;n posterior tambi&#233;n establecieron unos niveles asistenciales de ictus en funci&#243;n de los recursos asistenciales disponibles&#44; dividiendo a los hospitales en 3 niveles<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; De esta manera tenemos hospitales con Equipos de Ictus&#44; hospitales con UI y hospitales de Referencia de Ictus<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">En el a&#241;o 2008&#44; el Consejo Interterritorial del Ministerio de Salud y Pol&#237;tica Social aprob&#243; la Estrategia del Ictus del Sistema Nacional de Salud &#40;EISNS&#41;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46; La EISNS fue el consenso de todas las sociedades cient&#237;ficas y profesionales en el ictus y los representantes de las 17 comunidades aut&#243;nomas y el Instituto Nacional de Gesti&#243;n Sanitaria &#40;INGESA&#41;&#46; En ella se abarcaron diversos aspectos del ictus como la prevenci&#243;n&#44; atenci&#243;n en fase aguda&#44; rehabilitaci&#243;n e investigaci&#243;n&#46; Establece que cada comunidad aut&#243;noma &#40;CC&#46;AA&#46;&#41; debe realizar un plan de ictus regional&#44; donde cada una de ellas establezca los recursos que necesita para cumplir con los objetivos&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">En la actualidad en toda Europa muchos casos de ictus no se benefician del ingreso en una UI&#44; tal como se recomienda en la Declaraci&#243;n de Helsingborg y a pesar de las evidencias existentes respecto al beneficio de las UI&#46; La EISNS ha tratado de incrementar esta oferta reorientando los recursos asistenciales adecuados<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;23</span></a>&#46; Hemos querido evaluar los recursos existentes en atenci&#243;n al ictus agudo en el a&#241;o 2012 y compararlos con la encuesta previa del 2008 en un contexto donde la EISNS est&#225; vigente<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Material y m&#233;todo</span><p id="par0035" class="elsevierStylePara elsevierViewall">Se realiz&#243; una encuesta nacional entre enero y junio de 2012 en todas las CC&#46;AA&#46; con excepci&#243;n de las ciudades aut&#243;nomas de Ceuta y Melilla&#44; que fue coordinada por 2 representantes de cada una de las respectivas comunidades&#44; todos ellos miembros del GEECV con la premisa de no haber participado en la elaboraci&#243;n de la EISNS&#46; Estos&#44; a su vez trasladaron el cuestionario a los coordinadores de las UI o del Servicio de Neurolog&#237;a de cada hospital&#46; La encuesta incluy&#243; los &#237;tems que se analizaron en la encuesta de los recursos disponibles en el a&#241;o 2008&#46; Se recogieron datos de 136 hospitales espa&#241;oles de titularidad p&#250;blica obtenidos del Cat&#225;logo Nacional de Hospitales&#44; sin incluir los hospitales privados que no atienden a los pacientes no adscritos al Servicio Nacional de Salud&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se recopilaron datos sobre la disponibilidad de las UI en cada hospital y el n&#250;mero total de camas de las UI&#44; calculando las ratios UI&#47;poblaci&#243;n y cama de UI&#47;poblaci&#243;n en funci&#243;n del n&#250;mero de habitantes de cada comunidad&#44; consignando el n&#250;mero de UI por comunidad y aquellas provincias que carec&#237;an de las mismas&#46; Con el objeto de comprobar si las UI cumpl&#237;an con una dotaci&#243;n m&#237;nima imprescindible que garantizase sus beneficios se valor&#243; si dispon&#237;an de&#58; neur&#243;logo de guardia de presencia f&#237;sica 24<span class="elsevierStyleHsp" style=""></span>h&#47;7 d&#237;as&#44; monitorizaci&#243;n multipar&#225;metro no invasiva &#40;MMP&#41;&#44; enfermer&#237;a entrenada con una ratio por camas de UI de 1&#47;4-1&#47;6 y la disponibilidad de protocolos diagn&#243;stico-terap&#233;uticos propios&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Otro de los &#237;tems valorados fue el n&#250;mero de hospitales con programa de trombolisis intravenosa realizada por neur&#243;logos&#44; y el n&#250;mero de pacientes tratados durante el a&#241;o 2011 en cada centro y en cada comunidad respectivamente&#44; valorando el porcentaje de pacientes tratados respecto al total de pacientes ingresados con ictus isqu&#233;mico&#46; Se reflej&#243; el n&#250;mero de centros que contaban con experiencia en INV&#44; as&#237; como la disponibilidad horaria para administrar el tratamiento endovascular&#46; Se compilaron los datos de la accesibilidad a t&#233;cnicas de neuroimagen avanzadas en la fase aguda del ictus y de cu&#225;l era la t&#233;cnica disponible en cada caso&#44; ya fuese TC&#44; RM o ambas&#46; Tambi&#233;n se recogi&#243; el n&#250;mero de hospitales que dispon&#237;an de protocolos para la craniectom&#237;a descompresiva en el tratamiento del infarto maligno de la arteria cerebral media&#46; Por &#250;ltimo&#44; tambi&#233;n se document&#243; la existencia de programas de telemedicina en el tratamiento del ictus agudo y la poblaci&#243;n que no se beneficiaba de este recurso en el caso de que esa &#225;rea de poblaci&#243;n no contase con UI&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">Se recogieron datos de 136 hospitales espa&#241;oles&#46; Existen 45 UI en Espa&#241;a&#46; A excepci&#243;n de 3&#44; todas cuentan con el recurso imprescindible de tener un neur&#243;logo de presencia f&#237;sica las 24<span class="elsevierStyleHsp" style=""></span>h los 365 d&#237;as del a&#241;o&#46; El requisito de disponer de enfermer&#237;a entrenada en ictus con una ratio de una enfermera por cada 4-6 camas se cumple en todas ellas a excepci&#243;n de 4 UI&#44; &#40;compartida con el resto de la planta de hospitalizaci&#243;n&#41;&#46; Los otros 2 requisitos &#40;protocolos y MMP&#41; se cumpl&#237;an en 44 de ellas&#46; La disponibilidad de protocolos asistenciales tambi&#233;n relevante en los centros sin UI&#44; ya que 28 de los 38 hospitales cuentan con ellos &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; De los 38 hospitales en los que los neur&#243;logos tratan con trombolisis hay neur&#243;logo de presencia f&#237;sica en 8 y de guardia localizada en 13 de ellos&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">La implantaci&#243;n de las UI ha sido desigual en toda Espa&#241;a&#44; dado que aunque est&#225;n presentes en casi todas las autonom&#237;as &#40;94&#37;&#41;&#44; solo se cuenta con ellas en el 48&#37; de las capitales de provincia &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; En 22 provincias no hay UI&#44; 16 de las cuales cuentan con una poblaci&#243;n que supera los 300&#46;000 habitantes&#44; lo que justificar&#237;a la presencia de al menos 3 camas de UI en cada una de ellas&#46; No obstante&#44; en un n&#250;mero significativo de centros sin UI se dispone de los recursos diagn&#243;sticos y terap&#233;uticos recomendados &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; La carencia de UI es especialmente llamativa en comunidades como Andaluc&#237;a que solo cuenta con una UI en 2 de las 8 provincias&#44; o Galicia donde solo disponen de una UI y La Rioja que no tiene ninguna&#46; Al analizar la ratio cama de UI&#47;n&#250;mero de habitantes en cada CC&#46;AA&#46; observamos que solo Cantabria y Navarra cumplen con el objetivo de tener al menos una cama de UI&#47;100&#46;000 habitantes&#46; Al igual que en la encuesta anterior es Andaluc&#237;a la comunidad m&#225;s desfavorecida &#40;ratio de una cama de UI por mill&#243;n de habitantes&#41; y La Rioja que no dispone de ninguna cama&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">En lo relativo a los recursos diagn&#243;sticos para el estudio del ictus la disponibilidad es completa en todas las UI en cuanto al estudio arterial intra y extracraneal&#44; pudiendo disponer de estudio ultrasonogr&#225;fico y angiogr&#225;fico&#44; ya sea con arteriograf&#237;a convencional con TC o RM&#46; En todos los hospitales con UI hay t&#233;cnicas de neuroimagen avanzada para la valoraci&#243;n arterial y de la penumbra isqu&#233;mica&#59; en todos los centros que tratan ictus se dispone de una u otra&#44; y en 29 de ellos se cuenta con ambas &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46; No obstante&#44; en 24 de los centros que realizan trombolisis en fase aguda no est&#225; disponible m&#225;s que la TC&#46; Adem&#225;s en todos los hospitales con UI es posible realizar los estudios cardiol&#243;gicos&#44; tanto para la ecocardiograf&#237;a transtor&#225;cica como la transesof&#225;gica&#44; recursos que tambi&#233;n se hallan disponibles en el resto de hospitales que realizan trombolisis intravenosa&#46; En estos hospitales se dispone adem&#225;s de t&#233;cnicas de neuroimagen avanzada en 27 de ellos &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Existe un programa de trombolisis intravenosa coordinado por neur&#243;logos en 83 hospitales repartidos por todas las CC&#46;AA&#46;&#44; teniendo en 61 hospitales neur&#243;logo de guardia presencial a tiempo completo&#46; De los cuales solo en 7 se tratan menos de 5 pacientes por a&#241;o&#44; lo que representa una mejor&#237;a respecto a la encuesta previa&#44; que hasta 12&#44;5&#37; de los 80 hospitales trataban menos de 5 ictus por a&#241;o&#46; Aunque la tasa de administraci&#243;n de trombolisis intravenosa es variable en funci&#243;n de cada centro&#44; se ha asistido a un notable incremento en el n&#250;mero de pacientes tratados llegando en algunos centros hasta el 39&#37; del total de los pacientes ingresados con un ictus isqu&#233;mico&#44; con un total de 2&#46;345 tratamientos en todo el estado&#46; En hospitales sin UI se trata un n&#250;mero menor&#44; 20 UI y 15 centros sin UI tratan m&#225;s del 5&#37; de los ictus &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">tablas 1 y 3</a>&#41;&#46; El incremento en el n&#250;mero de tratamientos ha sido homog&#233;neo en todo el pa&#237;s&#44; incluyendo en esta evoluci&#243;n favorable a los centros que no disponen de UI&#46; En estos centros se tratan con un porcentaje variable que va desde el 0&#44;3 al 24&#37; de los pacientes &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Los mayores porcentajes de pacientes tratados con trombolisis se dan fundamentalmente en los grandes centros de Madrid y Barcelona&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">El recurso de la radiolog&#237;a intervencionista para el tratamiento del ictus en fase aguda est&#225; disponible en todas las autonom&#237;as con la excepci&#243;n de La Rioja&#44; aunque solo cuentan con este recurso 42 hospitales&#44; de los cuales 33 est&#225;n en hospitales con UI que cubren la asistencia de un total de 27 provincias &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">tablas 1 y 3</a>&#41;&#46; En este aspecto se ha producido tambi&#233;n un incremento respecto a la situaci&#243;n previa&#44; ya que est&#225; disponible de manera continua las 24<span class="elsevierStyleHsp" style=""></span>h durante todo el a&#241;o en 17 &#225;reas asistenciales&#44; se&#241;alar que en Catalu&#241;a y en Madrid la demanda asistencial se cubre con un sistema de nodos&#46; La disponibilidad de la cirug&#237;a del infarto maligno de la arteria cerebral media existe en 37 de los 45 centros que disponen de UI &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41; y en otros 9 centros en los que no hay UI &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">En el a&#241;o 2009 el recurso de la telemedicina solo estaba disponible en Baleares&#44; en la actualidad constatamos una mejor&#237;a al respecto pues se encuentra disponible en 5 &#225;reas geogr&#225;ficas&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discusi&#243;n</span><p id="par0080" class="elsevierStylePara elsevierViewall">La EISNS fue auspiciada por el Ministerio de Sanidad y Pol&#237;tica Social&#44; consensuada con todas las sociedades cient&#237;ficas implicadas en el proceso asistencial del ictus y suscrita por la totalidad de los gobiernos auton&#243;micos<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46; Para la consecuci&#243;n del objetivo de la EISNS las distintas CC&#46;AA&#46; deb&#237;an redactar un plan regional y establecer los recursos necesarios para poder cumplir con el objetivo de la EISNS en un plazo de 2 a&#241;os&#46; De esta manera se introducir&#237;an las mejoras en el proceso asistencial para que la asistencia fuese la &#243;ptima en relaci&#243;n con las evidencias cient&#237;ficas y as&#237; poder garantizar la equidad territorial&#46; Los datos disponibles en el momento de la aprobaci&#243;n de la EISNS constataban inequidades en la asistencia sanitaria&#44; de forma que la dotaci&#243;n de las infraestructuras disponibles era &#243;ptima en unas CC&#46;AA&#46;&#44; mientras que en otras era deficiente&#46; El objetivo del GEECV al realizar la primera &#171;Encuesta de recursos asistenciales al ictus en Espa&#241;a&#187; fue comprobar cu&#225;l era la situaci&#243;n real de la asistencia neurol&#243;gica del ictus agudo a final del a&#241;o 2008 y repetir la recogida de datos a los 2 a&#241;os con el objetivo de evaluar si se hab&#237;a producido una mejora en la asistencia a los pacientes con ictus agudo en un contexto donde la EISNS ya estaba vigente<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; Est&#225; fuera del prop&#243;sito de esta encuesta el an&#225;lisis del resto de los objetivos de EISNS que eran m&#225;s amplios e inclu&#237;an aspectos relevantes&#44; como la prevenci&#243;n primaria como secundaria de la enfermedad vascular&#44; la rehabilitaci&#243;n y reinserci&#243;n social&#44; adem&#225;s de mejorar la formaci&#243;n e investigaci&#243;n en la enfermedad vascular cerebral&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Las UI representan el mejor tratamiento del ictus y el que proporciona mayor beneficio en t&#233;rminos poblacionales<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#8211;27</span></a>&#46; Las UI disminuyen la probabilidad de muerte o incapacidad en todos los subgrupos de pacientes&#44; excepto en los pacientes con reducci&#243;n del nivel de conciencia&#44; y este beneficio se mantiene a largo plazo<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a>&#46; La monitorizaci&#243;n y valoraci&#243;n neurol&#243;gica precoces&#44; junto con el trabajo multidisciplinar se asocian a una menor mortalidad o dependencia tras el ictus<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a>&#46; La encuesta realizada en el a&#241;o 2009 mostr&#243; que la dotaci&#243;n de las UI era adecuada al analizar las variables de ratio de enfermer&#237;a&#44; monitorizaci&#243;n&#44; atenci&#243;n continuada y uso de protocolos de actuaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; No obstante&#44; la distribuci&#243;n de las mismas era irregular&#44; ya que estaban concentradas en grandes n&#250;cleos urbanos como Madrid y Barcelona&#44; y no se cumpl&#237;a el objetivo de tener al menos una cama de UI por cada 100&#46;000 habitantes<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; De esta manera se documentaron inequidades territoriales&#44; mostrando una dotaci&#243;n de infraestructuras claramente insuficiente en Andaluc&#237;a&#44; Galicia&#44; Castilla-La Mancha y La Rioja&#46; No obstante&#44; a pesar de no disponer de UI hay un n&#250;mero significativo de hospitales que cuentan con recursos importantes tanto para el diagn&#243;stico como para el tratamiento del ictus&#46; En este sentido Espa&#241;a no difiere del resto de pa&#237;ses de la Uni&#243;n Europea en los que se replican las carencias en la disponibilidad de UI<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46; A este respecto cabe destacar la relevancia de la iniciativa del Ministerio de Sanidad y Pol&#237;tica Social que persegu&#237;a incrementar la oferta de recursos disponibles y que no tiene paralelismo en los pa&#237;ses de nuestro medio&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Los datos actuales muestran un crecimiento del n&#250;mero de UI&#44; aunque todav&#237;a insuficiente para satisfacer las demandas asistenciales de manera &#243;ptima&#46; Se implantaron 3 UI en Catalu&#241;a y Pa&#237;s Vasco&#44; una en Asturias y otra en la Comunidad Valenciana&#46; De esta manera podemos documentar que persisten las desigualdades territoriales ya recogidas en la encuesta anterior&#44; sin mejor&#237;a en las comunidades que contaban con peor dotaci&#243;n&#46; En el grupo de las peor dotadas destacan Andaluc&#237;a y La Rioja&#44; aunque tambi&#233;n ocurre lo mismo en otras comunidades como Castilla-La Mancha y Galicia&#46; No se experiment&#243; ning&#250;n beneficio en el n&#250;mero de camas de UI disponibles por habitantes&#44; ya que el objetivo de disponer de una cama por cada 100&#46;000 habitantes solo se consigui&#243; en Cantabria&#46; En 22 provincias no hay UI lo que impide el acceso a las mismas a m&#225;s de 10&#46;000&#46;000 de personas&#44; 16 de las provincias cuentan con una poblaci&#243;n que supera los 300&#46;000 habitantes&#44; lo que hubiese justificado la presencia de al menos 3 camas de UI en cada una de ellas&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">En todas las UI se cumplen requisitos como la MMP o el uso de protocolos diagn&#243;stico-terap&#233;uticos&#44; adem&#225;s de un esquema de trabajo multidisciplinar&#46; Un aspecto que consideramos crucial como la presencia de neur&#243;logos de guardia <span class="elsevierStyleItalic">in situ</span> las 24<span class="elsevierStyleHsp" style=""></span>h se satisfizo en 41 de las 44 UI&#46; La presencia de neur&#243;logo para la atenci&#243;n continuada al ictus se ha relacionado con una mejor&#237;a en la calidad de la atenci&#243;n al ictus&#44; dado que facilita la valoraci&#243;n y acceso precoces al tratamiento&#44; mejorando as&#237; el pron&#243;stico<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a>&#46; La dotaci&#243;n de enfermer&#237;a es adecuada a los requisitos recomendados en general&#44; solo en 5 UI no se cumple la ratio adecuada de 1-4&#47;6 camas lo que debe ser modificado r&#225;pidamente&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">La disponibilidad de recursos diagn&#243;sticos en los sistemas de atenci&#243;n al ictus es crucial tanto para el diagn&#243;stico etiol&#243;gico&#44; como para el manejo en fase aguda con el uso de t&#233;cnicas de neuroimagen avanzada<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;33&#44;34</span></a>&#46; Estas &#250;ltimas mejoran la selecci&#243;n de los pacientes y han permitido avanzar en la aplicaci&#243;n de los nuevos tratamientos y nuevas indicaciones<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; En lo relativo a los recursos diagn&#243;sticos para el estudio del ictus la disponibilidad es completa en cuanto al estudio arterial tanto intra como extracraneal&#44; pudiendo contar en todas las UI con estudio ultrasonogr&#225;fico y angiogr&#225;fico&#44; ya sea con arteriograf&#237;a convencional como con TC o RM&#46; En todas las UI se disponen de t&#233;cnicas de neuroimagen avanzada para la valoraci&#243;n arterial y de penumbra isqu&#233;mica&#44; en todos los centros que tratan ictus se dispone de una u otra&#44; en 29 de ellos se cuenta con ambas&#44; aunque en 24 de los centros que usan trombolisis en fase aguda no est&#225; disponible m&#225;s que la TC convencional&#46; Adem&#225;s&#44; en todas las UI es posible realizar los estudios cardiol&#243;gicos&#44; disponiendo de ecocardiograf&#237;a transtor&#225;cica y la transesof&#225;gica&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">La trombolisis intravenosa es el tratamiento que ha demostrado mayor eficacia en el infarto cerebral agudo<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a>&#46; Para el desarrollo de la trombolisis intravenosa era necesaria la implantaci&#243;n del c&#243;digo ictus y este era uno de los objetivos de la EISNS&#46; Sin embargo&#44; a diferencia de los beneficios de las UI donde la inmensa mayor&#237;a de los pacientes con ictus se benefician de ellas&#44; la estrecha ventana terap&#233;utica as&#237; como sus m&#250;ltiples complicaciones hacen que en la mejor de las situaciones se est&#233; administrando al 10-15&#37; de los infartos cerebrales siendo las cifras habituales de un 3-5&#37;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;35&#44;36</span></a>&#46; En nuestra encuesta se recopilaron los datos de los 82 centros en los que este tratamiento se administra por parte de neur&#243;logos&#46; Dado que solo existen 45 UI en Espa&#241;a esta cifra traduce que en muchos centros que carecen de UI los neur&#243;logos espa&#241;oles han implantado programas de trombolisis&#46; A pesar de no administrarse el tratamiento en una UI este tratamiento tambi&#233;n es seguro cuando se hace de un modo protocolizado por neur&#243;logos entrenados<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#44;38</span></a>&#46; Est&#225; bien establecido que el porcentaje de complicaciones relacionadas con la trombolisis aumenta en aquellos centros que en los que se realizan menos de 5 tratamientos por a&#241;o<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#44; circunstancia que ocurre solo en 7 de los 82 centros que se administra este tratamiento por neur&#243;logos&#46; Llama la atenci&#243;n el incremento notable en la tasa de administraci&#243;n del tratamiento respecto del n&#250;mero total de pacientes ingresados con ictus isqu&#233;micos&#44; que llega a ser hasta del 39&#37;&#44; lo cual puede deberse en parte a la mayor experiencia en su uso y a la ampliaci&#243;n de la ventana de tratamiento hasta las 4&#44;5<span class="elsevierStyleHsp" style=""></span>h&#46; Tambi&#233;n influyen en este incremento que la experiencia acumulada con este tratamiento ha permitido que se pueda administrar de forma segura en indicaciones restrictivas no recogidas en los ensayos cl&#237;nicos iniciales y en la ficha t&#233;cnica del producto<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;40</span></a>&#46; Las mayores tasas de tratamiento se dan fundamentalmente en Madrid y Barcelona&#44; aunque Cantabria tambi&#233;n supera el 30&#37;&#46; Existe una gran variabilidad en el n&#250;mero de tratamientos administrados en cada CC&#46;AA&#46; encontrando hospitales con un anecd&#243;tico 0&#44;5&#37;&#46; Este hecho se puede explicar en parte por el n&#250;mero de UI existente en cada comunidad&#44; aunque no parece ser la &#250;nica causa&#46; Es labor de todos hacer un esfuerzo para que el m&#225;ximo n&#250;mero de pacientes puedan ser tratados con t-PA y ese objetivo se est&#225; consiguiendo al menos en parte a la vista del marcado crecimiento en el porcentaje de pacientes tratados&#46; Las UI y los centros con un bajo n&#250;mero de tratamientos anuales deber&#225;n analizar a qu&#233; nivel de la cadena asistencial se encuentra el problema &#40;reconocimiento por parte de la poblaci&#243;n de los s&#237;ntomas del ictus&#44; c&#243;digo ictus extra o intrahospitalario o de los tiempos de actuaci&#243;n y toma decisiones por parte de la guardia de Neurolog&#237;a&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">El INV no estaba pactado en los objetivos de la EISNS dado que su desarrollo y las evidencias cient&#237;ficas acerca de su uso en el ictus agudo eran menores en aquel momento&#46; No obstante&#44; s&#237; aparece entre los objetivos de la actualizaci&#243;n del PASI&#46; El INV es una alternativa real a la trombolisis intravenosa cuando esta no se puede emplear o no ha sido eficaz&#46; Existen diferentes t&#233;cnicas &#40;trombectom&#237;a mec&#225;nica&#44; trombolisis intraarterial o angioplastia&#41; con diferentes indicaciones y ventanas terap&#233;uticas que han mostrado beneficio en el tratamiento del ictus en la fase aguda<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#8211;45</span></a>&#46; El an&#225;lisis de esta encuesta revela que este recurso est&#225; disponible en todas las CC&#46;AA&#46; salvo La Rioja&#44; con centros que poseen la capacitaci&#243;n t&#233;cnica y la experiencia para realizar el procedimiento&#46; Aunque en muchos de los centros los pacientes solo pueden ser tratados en horario de ma&#241;ana&#44; encontramos que se ha producido una notable mejor&#237;a respecto a la situaci&#243;n que ten&#237;amos en el a&#241;o 2009&#46; Hemos pasado de disponer de solo 2 centros que ofreciesen esta terapia las 24<span class="elsevierStyleHsp" style=""></span>h del d&#237;a a poder realizar este tratamiento en 17 &#225;reas geogr&#225;ficas&#44; que en Madrid y Catalu&#241;a se estructura en forma de &#171;nodos&#187;&#44; con objeto de conseguir la m&#225;xima eficiencia de los recursos&#44; adem&#225;s de hacer la organizaci&#243;n sostenible en el tiempo&#46; El que un paciente se pueda beneficiar de un tratamiento o no dependiendo de la hora en que sufra el ictus es tan injusto que es necesario seguir trabajando para poder ofrecer esta terapia a todos nuestros ciudadanos&#46; Para ello se deben buscar soluciones organizativas que permitan adecuar los recursos t&#233;cnicos existentes en cada zona geogr&#225;fica&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">La opci&#243;n del tratamiento de recanalizaci&#243;n est&#225; limitada en pacientes que se encuentren distantes de los centros especializados&#44; que solo disponen de hospitales comarcales con profesionales no neur&#243;logos sin experiencia en este tratamiento&#46; Por otra parte&#44; no todos los hospitales deben atender a pacientes con ictus&#44; tal como se ha observado en estudios realizados en diferentes pa&#237;ses<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; Una alternativa que facilite el acceso precoz a este tratamiento es la telemedicina&#44; ya que permite duplicar el n&#250;mero de pacientes con ictus que reciben atenci&#243;n neurol&#243;gica especializada urgente&#44; doblar el n&#250;mero de tratamientos fibrinol&#237;ticos&#44; reducir significativamente el tiempo transcurrido hasta el inicio de la trombolisis en unos 50<span class="elsevierStyleHsp" style=""></span>min e incrementar el n&#250;mero de pacientes tratados en ventanas de 0-3<span class="elsevierStyleHsp" style=""></span>h&#59; adem&#225;s&#44; reducen en m&#225;s de un tercio el n&#250;mero de traslados interhospitalarios finales<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;47</span></a>&#46; En la actualidad el desarrollo de este recurso en nuestro pa&#237;s es insuficiente&#44; a pesar de que hay numerosas &#225;reas del territorio nacional en las que se dan condiciones como la insularidad o distancias que exceden una is&#243;crona &#243;ptima de 60<span class="elsevierStyleHsp" style=""></span>min para el traslado al centro de referencia&#44; que es lo que se considera recomendable<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46; Este procedimiento se implant&#243; inicialmente en Baleares&#44; a&#241;adi&#233;ndose posteriormente Barcelona y Sevilla obteniendo buenos resultados en t&#233;rminos de seguridad y eficacia<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a>&#46; En el a&#241;o 2011 se hab&#237;an a&#241;adido a estos 3 centros uno en Madrid y otro en Galicia&#44; as&#237; en 5 hospitales de referencia se pod&#237;an soslayar las limitaciones geogr&#225;ficas para el tratamiento trombol&#237;tico&#46; De esta forma una parte importante de la poblaci&#243;n no puede acceder a este recurso terap&#233;utico&#44; ya sea por la carencia de infraestructuras o por que la distancia al hospital con UI sobrepasa la is&#243;crona de 60<span class="elsevierStyleHsp" style=""></span>min deseable para administrar el tratamiento&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusi&#243;n</span><p id="par0120" class="elsevierStylePara elsevierViewall">El prop&#243;sito de esta encuesta fue analizar con qu&#233; recursos contamos a nivel nacional para la asistencia al ictus&#44; su distribuci&#243;n a nivel nacional&#44; y si estos recursos hab&#237;an mejorado tras el compromiso adquirido con la aprobaci&#243;n de la EISNS&#46; Aunque la situaci&#243;n al ictus ha mejorado en relaci&#243;n con los datos de la encuesta del a&#241;o 2008&#44; hemos podido documentar la insuficiente implantaci&#243;n de las UI a lo largo de todo el territorio&#44; comprobando adem&#225;s&#44; que las desigualdades geogr&#225;ficas persisten&#44; pues las UI se concentran en los grandes n&#250;cleos urbanos&#44; y que su promoci&#243;n es marginal en algunas de las CC&#46;AA&#46; Aunque se ha producido un incremento notable en los tratamientos intravenosos o endovascular&#44; el n&#250;mero de pacientes tratados es insuficiente&#44; y aqu&#237; tambi&#233;n se reproduce la desigualdad&#46; La disponibilidad de recursos diagn&#243;sticos es buena en la mayor parte de los centros pudiendo contar todas las UI con los requerimientos adecuados&#46; Finalmente&#44; la telemedicina como recurso para paliar las desigualdades geogr&#225;ficas ha tenido un desarrollo escaso hasta el momento&#46; Por tanto&#44; consideramos que es necesario avanzar en el desarrollo de la EISNS para as&#237; cumplir con sus objetivos&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicto de intereses</span><p id="par0125" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Introducci&#243;n"
            2 => "Material y m&#233;todos"
            3 => "Resultados"
            4 => "Conclusi&#243;n"
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          "identificador" => "xpalclavsec347647"
          "titulo" => "Palabras clave"
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          "identificador" => "xres368480"
          "titulo" => array:5 [
            0 => "Abstract"
            1 => "Introduction"
            2 => "Material and methods"
            3 => "Results"
            4 => "Conclusion"
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        ]
        3 => array:2 [
          "identificador" => "xpalclavsec347648"
          "titulo" => "Keywords"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Material y m&#233;todo"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Resultados"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discusi&#243;n"
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          "identificador" => "sec0020"
          "titulo" => "Conclusi&#243;n"
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        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflicto de intereses"
        ]
        9 => array:1 [
          "titulo" => "Bibliograf&#237;a"
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      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-02-19"
    "fechaAceptado" => "2013-06-17"
    "PalabrasClave" => array:2 [
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec347647"
          "palabras" => array:4 [
            0 => "Unidad de ictus"
            1 => "Tratamiento ictus"
            2 => "Encuesta recursos"
            3 => "Trombolisis"
          ]
        ]
      ]
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec347648"
          "palabras" => array:4 [
            0 => "Stroke unit"
            1 => "Stroke treatment"
            2 => "Stroke facilities survey"
            3 => "Thrombolysis"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La Estrategia del Ictus del Sistema Nacional de Salud &#40;EISNS&#41; fue un documento de consenso entre las distintas administraciones y sociedades cient&#237;ficas que se desarroll&#243; con el objetivo de mejorar la calidad del proceso asistencial y garantizar la equidad territorial&#46; Nuestro objetivo fue analizar los recursos asistenciales existentes y si se hab&#237;a cumplido el objetivo de la EISNS&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La encuesta sobre los recursos disponibles se realiz&#243; por un comit&#233; de neur&#243;logos de cada una de las comunidades aut&#243;nomas &#40;<span class="elsevierStyleSmallCaps">CC</span>&#46;AA&#41;&#44; los cuales tambi&#233;n realizaron la encuesta de 2008&#46; Los &#237;tems incluidos fueron el n&#250;mero de Unidades de Ictus &#40;UI&#41;&#44; su dotaci&#243;n &#40;monitorizaci&#243;n&#44; neur&#243;logo 24<span class="elsevierStyleHsp" style=""></span>h&#47;7 d&#237;as&#44; ratio enfermer&#237;a&#44; protocolos&#41;&#44; ratio cama UI&#47;100&#46;000 habitantes&#44; recursos diagn&#243;sticos &#40;ecograf&#237;a card&#237;aca y arterial cerebral&#44; neuroimagen avanzada&#41;&#44; realizaci&#243;n de trombolisis intravenosa&#44; intervencionismo neurovascular &#40;INV&#41;&#44; cirug&#237;a del infarto maligno de la arteria cerebral media &#40;ACM&#41; y disponibilidad de la telemedicina&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron datos de 136 hospitales&#46; Existen 45 UI distribuidas de un modo desigual&#46; La relaci&#243;n cama de UI por habitantes y comunidad aut&#243;noma oscil&#243; entre 1&#47;74&#46;000 a 1&#47;1&#46;037&#46;000 habitantes&#44; cumpliendo el objetivo solo Cantabria y Navarra&#46; Se realizaron por neur&#243;logos 3&#46;237 trombolisis intravenosas en 83 hospitales&#44; con un porcentaje respecto del total de ictus isqu&#233;mico entre el 0&#44;3 y el 33&#44;7&#37;&#46; Los hospitales sin UI ten&#237;an una disponibilidad variable de recursos&#46; Se realiza INV en todas las CC&#46;AA salvo La Rioja&#44; la disponibilidad del INV 24<span class="elsevierStyleHsp" style=""></span>h&#47;7 d&#237;as solo existe en 17 ciudades&#46; Hay 46 centros con cirug&#237;a del infarto maligno de la ACM y 5 con telemedicina&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La asistencia al ictus ha mejorado en cuanto al incremento de hospitales participantes&#44; la mayor aplicaci&#243;n de trombolisis intravenosa y procedimientos endovasculares&#44; tambi&#233;n en la cirug&#237;a del infarto maligno de la ACM&#44; pero con insuficiente implantaci&#243;n de UI y de la telemedicina&#46; La disponibilidad de recursos diagn&#243;sticos es buena en la mayor&#237;a de las UI&#44; e irregular en el resto de hospitales&#46; Las distintas CC&#46;AA deben avanzar para garantizar el mejor tratamiento y equidad territorial&#44; y as&#237; conseguir el objetivo de la EISNS&#46;</p>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The Spanish Health System&#39;s stroke care strategy &#40;EISNS&#41; is a consensus statement that was drawn up by various government bodies and scientific societies with the aim of improving quality throughout the care process and ensuring equality among regions&#46; Our objective is to analyse existing healthcare resources and establish whether they have met EISNS targets&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The survey on available resources was conducted by a committee of neurologists representing each of Spain&#39;s regions&#59; the same committee also conducted the survey of 2008&#46; The items included were the number of stroke units &#40;SU&#41;&#44; their resources &#40;monitoring&#44; neurologists on call 24<span class="elsevierStyleHsp" style=""></span>h&#47;7d&#44; nurse ratio&#44; protocols&#41;&#44; SU bed ratio&#47;100&#160;000 inhabitants&#44; diagnostic resources &#40;cardiac and cerebral arterial ultrasound&#44; advanced neuroimaging&#41;&#44; performing iv thrombolysis&#44; neurovascular interventional radiology &#40;neuro VIR&#41;&#44; surgery for malignant middle cerebral artery &#40;MCA&#41; infarctions and telemedicine availability&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We included data from 136 hospitals and found 45 Stroke Units distributed unequally among regions&#46; The ratio of SU beds to residents ranged from 1&#47;74&#44;000 to 1&#47;1&#44;037&#44;000 inhabitants&#59; only the regions of Cantabria and Navarre met the target&#46; Neurologists performed 3&#44;237 intravenous thrombolysis procedures in 83 hospitals&#59; thrombolysis procedures compared to the total of ischaemic strokes yielded percentages ranging from 0&#46;3 to 33&#46;7&#37;&#46; Hospitals without SUs showed varying levels of available resources&#46; Neuro VIR is performed in every region except La Rioja&#44; and VIR is only available on a 24<span class="elsevierStyleHsp" style=""></span>h&#47;7 d basis in 17 cities&#46; Surgery for malignant MCA infarction is performed in 46 hospitals&#44; and 5 have telemedicine&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Stroke care has improved in terms of numbers of participating hospitals&#44; the increased use of intravenous thrombolysis and endovascular procedures&#44; and surgery for malignant MCA infarction&#46; Implementation of SUs and telemedicine remain insufficient&#46; The availability of diagnostic resources is good in most SUs and irregular in other hospitals&#46; Regional governments should strive to ensure better care and territorial equality&#44; which would achieve the EISNS objectives&#46;</p>"
      ]
    ]
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Este trabajo fue presentado parcialmente como comunicaci&#243;n oral a la LXIV Reuni&#243;n Anual de la Sociedad Espa&#241;ola de Neurolog&#237;a&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">DCT&#58; d&#250;plex carot&#237;deo y transcraneal&#59; ECC&#58; ecograf&#237;a transtor&#225;cica y transesof&#225;gica&#59; IA&#58; imagen avanzada&#59; IA24&#58; imagen avanzada 24<span class="elsevierStyleHsp" style=""></span>h&#59; L&#58; localizada&#59; N&#58; guardia neurolog&#237;a&#59; ND&#58; no disponible&#59; P&#58; tiempo completo&#59; PR&#58; protocolos&#59; Q&#58; cirug&#237;a cerebral media maligna&#59; RI&#58; intervencionismo&#59; RI24&#58; intervencionismo disponible 24<span class="elsevierStyleHsp" style=""></span>h&#59; TI&#58; teleictus&#59; TPA&#58; n&#250;mero trombolisis intravenosas&#59; &#37;&#58; porcentaje de tratamiento respecto al total de ingresos&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">N&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">ECA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">ECC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">IA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">IA 24&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">TPA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">RI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">RI24&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Q&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleSmallCaps">V</span>irgen de las Nieves&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">M&#225;laga &#40;Victoria&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Extremadura&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Castilla-La Mancha&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Cuenca&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">Toledo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">P&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Ciudad Real&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Castilla y Le&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Soria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Ponferrada&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">P&#46; Asturias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
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                  """
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        "descripcion" => array:1 [
          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Procedimientos diagn&#243;sticos y tratamientos de los hospitales que tratan r-TPA sin UI en 2011</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">C&#58; compartida&#59; E&#58; evoluci&#243;n&#59; MMP&#58; monitorizaci&#243;n&#59; N&#46;24&#58; neur&#243;logo presencia 24<span class="elsevierStyleHsp" style=""></span>h&#59; PR&#58; protocolo&#59; RE&#58; ratio enfermer&#237;a&#47;cama&#59; SC&#58; sin cambios&#59; 4<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">I&#58;</span> cumplir 4 items&#46;</p>"
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                0 => """
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                  \t\t\t\t" style="border-bottom: 2px solid black">Comunidad&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">RE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">MMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">PR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">4<span class="elsevierStyleSmallCaps">I</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleSmallCaps">V</span>irgen del Roc&#237;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">General&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#47;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nueva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Castilla-La Mancha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Albacete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#47;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Castilla y Le&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Valladolid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#47;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Le&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#47;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Burgos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#47;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Galicia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Santiago&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asturias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#47;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cabue&#241;es&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#47;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#193;lava&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Nueva&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Arag&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Servet&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Navarra&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Complejo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cl&#237;nica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Baleares&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Son Espases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Canarias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Madrid&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Doce Octubre&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">La Paz&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Ram&#243;n y Cajal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Catalu&#241;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Bellvitge&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Sabadell&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Nueva&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab554335.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Listado de UI existentes en 2011 y recursos disponibles</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Tabla 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
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                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Castell&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">TC&#47;RM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">70&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">La Fe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TC&#47;RM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">General&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">TC&#47;RM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Castilla-La Mancha&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Albacete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Castilla y Le&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Valladolid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">TC&#47;RM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Le&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">TC&#47;RM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Burgos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Baleares&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Son Espases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">TC&#47;RM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Canarias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Candelaria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">TC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Insular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">TC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negr&#237;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Madrid&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Doce&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">La Paz&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TC&#47;RM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ram&#243;n y Cajal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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Información del artículo
ISSN: 02134853
Idioma original: Español
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2021 Enero 53 20 73
2020 Diciembre 35 19 54
2020 Noviembre 53 16 69
2020 Octubre 39 15 54
2020 Septiembre 29 14 43
2020 Agosto 45 20 65
2020 Julio 19 13 32
2020 Junio 31 20 51
2020 Mayo 34 13 47
2020 Abril 27 6 33
2020 Marzo 26 23 49
2020 Febrero 40 19 59
2020 Enero 25 16 41
2019 Diciembre 42 23 65
2019 Noviembre 30 11 41
2019 Octubre 33 10 43
2019 Septiembre 32 13 45
2019 Agosto 31 10 41
2019 Julio 52 19 71
2019 Junio 80 18 98
2019 Mayo 211 52 263
2019 Abril 65 33 98
2019 Marzo 26 9 35
2019 Febrero 29 10 39
2019 Enero 39 11 50
2018 Diciembre 20 10 30
2018 Noviembre 36 20 56
2018 Octubre 39 14 53
2018 Septiembre 20 15 35
2018 Agosto 7 1 8
2018 Julio 9 3 12
2018 Junio 22 0 22
2018 Mayo 21 7 28
2018 Abril 22 5 27
2018 Marzo 9 1 10
2018 Febrero 14 3 17
2018 Enero 20 0 20
2017 Diciembre 11 2 13
2017 Noviembre 29 7 36
2017 Octubre 15 3 18
2017 Septiembre 15 6 21
2017 Agosto 32 16 48
2017 Julio 27 4 31
2017 Junio 19 18 37
2017 Mayo 26 13 39
2017 Abril 28 13 41
2017 Marzo 28 8 36
2017 Febrero 23 10 33
2017 Enero 19 6 25
2016 Diciembre 34 7 41
2016 Noviembre 30 8 38
2016 Octubre 49 18 67
2016 Septiembre 36 12 48
2016 Agosto 35 7 42
2016 Julio 28 5 33
2016 Junio 27 12 39
2016 Mayo 37 23 60
2016 Abril 34 22 56
2016 Marzo 29 21 50
2016 Febrero 26 14 40
2016 Enero 29 11 40
2015 Diciembre 50 19 69
2015 Noviembre 45 9 54
2015 Octubre 41 16 57
2015 Septiembre 44 14 58
2015 Agosto 33 18 51
2015 Julio 28 17 45
2015 Junio 24 7 31
2015 Mayo 43 18 61
2015 Abril 36 27 63
2015 Marzo 54 11 65
2015 Febrero 37 14 51
2015 Enero 28 10 38
2014 Diciembre 41 12 53
2014 Noviembre 31 13 44
2014 Octubre 37 26 63
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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