Letter - Therapy
Inadequate response to antiplatelet therapy in Sneddon's syndrome. Time to re-evaluate management recommendations?
Lido
2359
Vezesque se leu este artigo
686
Total PDF
1673
Total HTML
Compartilhar estatísticas
array:23 [ "pii" => "S0365059624000783" "issn" => "03650596" "doi" => "10.1016/j.abd.2024.01.001" "estado" => "S300" "fechaPublicacion" => "2024-09-01" "aid" => "949" "copyright" => "Sociedade Brasileira de Dermatologia" "copyrightAnyo" => "2024" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "pt" => array:18 [ "pii" => "S266627522400081X" "issn" => "26662752" "doi" => "10.1016/j.abdp.2024.04.019" "estado" => "S300" "fechaPublicacion" => "2024-09-01" "aid" => "949" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "pt" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Cartas ‐ Terapia</span>" "titulo" => "Resposta inadequada à terapia antiplaquetária na síndrome de Sneddon. É hora de reavaliar as recomendações de manejo?" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "780" "paginaFinal" => "783" ] ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2542 "Ancho" => 1675 "Tamanyo" => 875023 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Livedo racemoso na síndrome de Sneddon.</span> (A–B) Observe a largura das ramificações (> 1 cm) na região glútea e extremidades inferiores da paciente com síndrome de Sneddon e deficiência de proteína S.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Cristóbal Lecaros, Gabriela Coulon, Francisca Reculé, Alex Castro, Constanza Del Puerto" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Cristóbal" "apellidos" => "Lecaros" ] 1 => array:2 [ "nombre" => "Gabriela" "apellidos" => "Coulon" ] 2 => array:2 [ "nombre" => "Francisca" "apellidos" => "Reculé" ] 3 => array:2 [ "nombre" => "Alex" "apellidos" => "Castro" ] 4 => array:2 [ "nombre" => "Constanza" "apellidos" => "Del Puerto" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0365059624000783" "doi" => "10.1016/j.abd.2024.01.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059624000783?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S266627522400081X?idApp=UINPBA00008Z" "url" => "/26662752/0000009900000005/v2_202409060549/S266627522400081X/v2_202409060549/pt/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S0365059624001211" "issn" => "03650596" "doi" => "10.1016/j.abd.2023.07.017" "estado" => "S300" "fechaPublicacion" => "2024-09-01" "aid" => "980" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter - Therapy</span>" "titulo" => "Multirefractory bullous pemphigoid, psoriasis and psoriatic arthritis successfully treated with guselkumab" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "783" "paginaFinal" => "785" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 573 "Ancho" => 1005 "Tamanyo" => 130653 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Complete resolution of Psoriasis Plaques (PASI0) and no new bullous pemphigoid lesions after 2-months with guselkumab.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Francisco José Rodríguez-Cuadrado, Gaston Roustan-Gullón, Dolores Suárez-Massa, Mercedes Hospital-Gil" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Francisco José" "apellidos" => "Rodríguez-Cuadrado" ] 1 => array:2 [ "nombre" => "Gaston" "apellidos" => "Roustan-Gullón" ] 2 => array:2 [ "nombre" => "Dolores" "apellidos" => "Suárez-Massa" ] 3 => array:2 [ "nombre" => "Mercedes" "apellidos" => "Hospital-Gil" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275224001401" "doi" => "10.1016/j.abdp.2024.06.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275224001401?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059624001211?idApp=UINPBA00008Z" "url" => "/03650596/0000009900000005/v2_202409130645/S0365059624001211/v2_202409130645/en/main.assets" ] "itemAnterior" => array:17 [ "pii" => "S0365059624001156" "issn" => "03650596" "doi" => "10.1016/j.abd.2023.08.017" "estado" => "S300" "fechaPublicacion" => "2024-09-01" "aid" => "974" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter - Therapy</span>" "titulo" => "Bullous pemphigoid successfully treated with dupilumab" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "778" "paginaFinal" => "780" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1205 "Ancho" => 905 "Tamanyo" => 128894 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lesions resolved with post-inflammatory hyperpigmantation.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Daniela de Abreu e Silva Martinez, Amanda de Freitas Sampaio Periquito, Graciela Galva Roa, João Pedro Lupi, Curt Mafra Treu, Omar Lupi" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Daniela de Abreu e Silva" "apellidos" => "Martinez" ] 1 => array:2 [ "nombre" => "Amanda de Freitas Sampaio" "apellidos" => "Periquito" ] 2 => array:2 [ "nombre" => "Graciela Galva" "apellidos" => "Roa" ] 3 => array:2 [ "nombre" => "João Pedro" "apellidos" => "Lupi" ] 4 => array:2 [ "nombre" => "Curt Mafra" "apellidos" => "Treu" ] 5 => array:2 [ "nombre" => "Omar" "apellidos" => "Lupi" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059624001156?idApp=UINPBA00008Z" "url" => "/03650596/0000009900000005/v2_202409130645/S0365059624001156/v2_202409130645/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter - Therapy</span>" "titulo" => "Inadequate response to antiplatelet therapy in Sneddon's syndrome. Time to re-evaluate management recommendations?" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "780" "paginaFinal" => "783" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Cristóbal Lecaros, Gabriela Coulon, Francisca Reculé, Alex Castro, Constanza Del Puerto" "autores" => array:5 [ 0 => array:3 [ "nombre" => "Cristóbal" "apellidos" => "Lecaros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Gabriela" "apellidos" => "Coulon" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Francisca" "apellidos" => "Reculé" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Alex" "apellidos" => "Castro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:4 [ "nombre" => "Constanza" "apellidos" => "Del Puerto" "email" => array:1 [ 0 => "mdelpuerto@alemana.cl" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Dermatology, Faculty of Medicine, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Pathology, Faculty of Medicine, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2208 "Ancho" => 3349 "Tamanyo" => 2227547 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Histological features of occlusive vasculopathy in Sneddon Syndrome</span>. (A‒B) Small arteries in the deep dermis and hypodermis with mural thickening and intimal hyperplasia (Hematoxylin & eosin, 4× and 10×). (C) Stenosis and obliteration of the lumen of a vessel (Hematoxylin & eosin, 40×). (D) Signs of re-tunneling and neovascularization without vasculitis (Hematoxylin & eosin, 40×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 46-year-old woman presented with asymptomatic violaceous macules on her skin for over 20 years. She had hypertension and had suffered an ischemic stroke at age 38, currently treated with enalapril, aspirin, and rosuvastatin. Despite these drugs, she had a second ischemic stroke at age 46, causing secondary dysarthria, anomic aphasia, and right-sided hemiparesis. She also had a long history of migraines since her youth and had experienced one miscarriage. The physical exam revealed asymptomatic broken reticulated violaceous macules on her arms, trunk, buttocks, and legs (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">A wide, deep skin biopsy showed multiple small arteries with thickening of the wall, intimal hyperplasia, stenosis, and lumen obliteration, with secondary signs of re-tunneling and neo-vascularization in the reticular dermis and subcutis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Cerebral magnetic resonance angiography revealed infarcts in the left frontal insular, right parietal and right posterior inferior cerebellar areas and parenchymal sequelae in the territory irrigated by the right and left medial cerebral artery. Echocardiogram and 24-h Holter electrocardiography were normal. Prothrombin time was 65%, INR 1.38, ANA 1/80 speckled pattern. Anti-DNA, anti-ENA, ANCA and Antiphospholipid (APL) antibodies were negative. Thrombophilia testing revealed Protein S deficiency. A Sneddon syndrome (SS) APL (-) with Protein S deficiency was diagnosed, and rivaroxaban was initiated.</p><p id="par0020" class="elsevierStylePara elsevierViewall">SS is an underdiagnosed neurocutaneous vasculopathy comprising small and medium-sized arteries, with an estimated incidence of 4 per million per year with a median age of 40 years.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Its etiology is poorly understood, although autoimmune and thrombotic mechanisms have been proposed. An autosomal recessive condition of SS with CERC1 mutations (encoding adenosine deaminase 2) has been described.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">SS is characterized by central nervous system manifestations (headaches, multiple strokes, cognitive impairment), persistent livedo racemosa, hypertension, cardiac valvulopathy, and less frequent renal and ocular involvement.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> SS is classified according to the presence of Anti-Phospholipid (APL) antibodies in two groups: SS<span class="elsevierStyleInf">APL-</span> and SS<span class="elsevierStyleInf">APL+</span>.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In patients with SS<span class="elsevierStyleInf">APL-</span> it is important to consider other causes of thrombophilia, as in a recent series, 27% of patients who underwent thrombophilia testing had positive results.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Patients with SS<span class="elsevierStyleInf">APL+</span> present with thinner branching livedo macules, have a higher frequency of thrombocytopenia, seizures, and chorea.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5</span></a> Patients with SS<span class="elsevierStyleInf">APL-</span> present with a higher number of strokes before diagnosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The treatment recommendations differ for patients with SS<span class="elsevierStyleInf">APL-</span> and SS<span class="elsevierStyleInf">APL+</span>.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–8</span></a> For early stages of SS<span class="elsevierStyleInf">APL-</span> regular monitoring with brain imaging is recommended, and in case of prodromic symptoms, prescription of low-dose aspirin. After an ischemic event, antiplatelet medications are the first-line treatment.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> For SS<span class="elsevierStyleInf">APL+</span> patients, similar management recommendations are suggested initially, but in the event of arterial thrombosis anticoagulant therapy is recommended.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This difference is based on two retrospective series.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Francès et al. followed 46 patients (19 SS<span class="elsevierStyleInf">APL+</span> and 27 SS<span class="elsevierStyleInf">APL-</span>) for six years.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Authors highlight that among SS<span class="elsevierStyleInf">APL+</span> patients, those who received anticoagulants had significantly fewer strokes than those on antiplatelet therapy. However, in SS<span class="elsevierStyleInf">APL-</span> subgroup there were no differences in the number of strokes regardless of therapy.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Bottin et al. followed 53 SS<span class="elsevierStyleInf">APL–</span> patients for twenty years<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and found no significant differences in ischemic events between these two therapies.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Nevertheless, the recently published series by Starmans et al. raises questions regarding these recommendations.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In this retrospective study of 53 patients (14 SS<span class="elsevierStyleInf">APL+</span> and 39 SS<span class="elsevierStyleInf">APL-</span>) with 21 years of follow-up, some patients were treated with antiplatelet therapy and some with anticoagulation, regardless of APL titers. During follow-up, patients with oral anticoagulation had significantly longer disease-free survival, as the time to first stroke recurrence in this group was twice as long as those receiving antiplatelet therapy (46 vs. 26.5 months, respectively). The authors recommend initiating antiplatelet therapy and switching to oral anticoagulation therapy early after any recurrent ischemic episode.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Our case report emphasizes that an extensive workout is needed in these patients given the higher risk of concomitant thrombophilia. The association between SS and Protein S deficiency has been previously reported.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Also, our case shows that antiplatelet therapy may not be sufficient for disease control in SS<span class="elsevierStyleInf">APL-</span> patients (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Given the importance of preventing early onset dementia, direct-acting oral anticoagulants – which have demonstrated similar efficacy to vitamin K antagonists with lower risk of intracranial hemorrhage in patients with ischemic strokes and atrial fibrillation<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> – should strongly be considered in symptomatic SS<span class="elsevierStyleInf">APL-</span> patients.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Cristóbal Lecaros: The study concept and design; data collection, analysis and interpretation; writing of the manuscript or critical review of important intellectual content; critical review of the literature; final approval of the final version of the manuscript.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Gabriela Coulon: The study concept and design; data collection, analysis and interpretation; writing of the manuscript or critical review of important intellectual content; critical review of the literature; final approval of the final version of the manuscript.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Francisca Reculé: The study concept and design; data collection, analysis and interpretation; writing of the manuscript or critical review of important intellectual content; critical review of the literature; final approval of the final version of the manuscript.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Alex Castro: Intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; writing of the manuscript or critical review of important intellectual content; critical review of the literature; final approval of the final version of the manuscript.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Constanza Del Puerto: The study concept and design; data collection, analysis and interpretation; writing of the manuscript or critical review of important intellectual content; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; final approval of the final version of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-09-20" "fechaAceptado" => "2024-01-12" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Faculty of Medicine, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1866 "Ancho" => 1675 "Tamanyo" => 458553 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Livedo racemosa in Sneddon syndrome</span>. (A‒B) Extended violaceous irregular reticular macules on the hands and trunk.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2542 "Ancho" => 1675 "Tamanyo" => 875023 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Livedo racemosa in Sneddon syndrome</span>. (A‒B) Note the width of the branches (wider than 1 cm) at the buttocks and lower extremities of a patient with Sneddon syndrome and Protein S deficiency.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2208 "Ancho" => 3349 "Tamanyo" => 2227547 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Histological features of occlusive vasculopathy in Sneddon Syndrome</span>. (A‒B) Small arteries in the deep dermis and hypodermis with mural thickening and intimal hyperplasia (Hematoxylin & eosin, 4× and 10×). (C) Stenosis and obliteration of the lumen of a vessel (Hematoxylin & eosin, 40×). (D) Signs of re-tunneling and neovascularization without vasculitis (Hematoxylin & eosin, 40×).</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">ACO, Anticoagulation therapy; DS, Disease Survival; SS<span class="elsevierStyleInf">APL-</span>, Sneddon Syndrome not associated with Antiphospholipid Antibodies; SS<span class="elsevierStyleInf">APL+</span>, Sneddon Syndrome associated with Antiphospholipid Antibodies.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th 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" scope="col" style="border-bottom: 2px solid black">Series \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Number of patients \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Follow up \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Therapy<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Outcome \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frances et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></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">46 patients \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 " rowspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6-years</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">SS<span class="elsevierStyleInf">APL+</span> \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">0.06 Strokes per year \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 SS<span class="elsevierStyleInf">APL+</span> \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">ACO (11) \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">0.5 Strokes per year \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 SS<span class="elsevierStyleInf">APL-</span></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">Antiplatelet (5) \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 " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.056 Strokes per year</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SS<span class="elsevierStyleInf">APL-</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ACO (10) \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 " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.08 Strokes per year</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antiplatelet (18) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bottin et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56 SS<span class="elsevierStyleInf">APL-</span> patients</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20-years</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">Antiplatelet (42) \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">3% stroke recurrence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ACO (10) \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">2.7% stroke recurrence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Starmans et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 patients</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28-months</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">ACO \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">46 months DS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antiplatelet \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">26.5 months DS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3652821.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Number of patients.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reported treatments and outcomes in published series of Sneddon’s syndrome.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sneddon syndrome: under diagnosed disease, complex clinical manifestations and challenging diagnosis. A case-based review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.S. Kong" 1 => "A. Azarfar" 2 => "N. Bhanusali" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00296-020-04625-1" "Revista" => array:6 [ "tituloSerie" => "Rheumatol Int." "fecha" => "2021" "volumen" => "41" "paginaInicial" => "987" "paginaFinal" => "991" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32533291" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early-onset stroke and vasculopathy associated with mutations in ADA2" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Q. Zhou" 1 => "D. Yang" 2 => "A.K. Ombrello" 3 => "A.V. Zavialov" 4 => "C. Toro" 5 => "A.V. Zavialov" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1307361" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med." "fecha" => "2014" "volumen" => "370" "paginaInicial" => "911" "paginaFinal" => "920" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24552284" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sneddon syndrome: a comprehensive overview" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Debopam" 1 => "S. Cobb" 2 => "K. Arya" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Stroke Cerebrovasc Dis." "fecha" => "2019" "volumen" => "28" "paginaInicial" => "2098" "paginaFinal" => "2108" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sneddon syndrome: a comprehensive clinical review of 53 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "N.L.P. Starmans" 1 => "M.R. van Dijk" 2 => "L.J. Kappelle" 3 => "C.J.M. Frijns" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00415-021-10407-x" "Revista" => array:6 [ "tituloSerie" => "J Neurol." "fecha" => "2021" "volumen" => "268" "paginaInicial" => "2450" "paginaFinal" => "2457" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33515066" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sneddon syndrome with or without antiphospholipid antibodies. A comparative study in 46 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C. Francès" 1 => "T. Papo" 2 => "B. Wechsler" 3 => "J.L. Laporte" 4 => "V. Biousse" 5 => "J.C. Piette" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00005792-199907000-00001" "Revista" => array:6 [ "tituloSerie" => "Medicine (Baltimore)." "fecha" => "1999" "volumen" => "78" "paginaInicial" => "209" "paginaFinal" => "219" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10424203" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Strokes in Sneddon syndrome without antiphospholipid antibodies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L. Bottin" 1 => "C. Francès" 2 => "D. de Zuttere" 3 => "P.Y. Boëlle" 4 => "I.P. Muresan" 5 => "S. Alamowitch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ana.24382" "Revista" => array:6 [ "tituloSerie" => "Ann Neurol." "fecha" => "2015" "volumen" => "77" "paginaInicial" => "817" "paginaFinal" => "829" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25628239" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anticardiolipin antibodies in Sneddon’s syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L.A. Kalashnikova" 1 => "E.L. Nasonov" 2 => "A.E. Kushekbaeva" 3 => "L.A. Gracheva" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1212/wnl.40.3_part_1.464" "Revista" => array:6 [ "tituloSerie" => "Neurology." "fecha" => "1990" "volumen" => "40" "paginaInicial" => "464" "paginaFinal" => "467" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2314589" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antiphospholipid-negative Sneddon’s syndrome: a comprehensive overview of a rare entity" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Assan" 1 => "L. Bottin" 2 => "C. Francès" 3 => "P. Moguelet" 4 => "S. Tavolaro" 5 => "A. Barbaud" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.annder.2021.08.007" "Revista" => array:6 [ "tituloSerie" => "Ann Dermatol Vénéréol." "fecha" => "2022" "volumen" => "149" "paginaInicial" => "3" "paginaFinal" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34740467" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sneddon syndrome associated with Protein S deficiency" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Sayin" 1 => "S.G. Bilgili" 2 => "A.S. Karadag" 3 => "T. Tombul" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Indian J Dermatol Venereol Leprol." "fecha" => "2012" "volumen" => "78" "paginaInicial" => "407" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Direct oral anticoagulants versus vitamin K antagonists after recent ischemic stroke in patients with atrial fibrillation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.J. Seiffge" 1 => "M. Paciaroni" 2 => "D. Wilson" 3 => "M. Koga" 4 => "K. Macha" 5 => "M. Cappellari" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ana.25489" "Revista" => array:6 [ "tituloSerie" => "Ann Neurol." "fecha" => "2019" "volumen" => "85" "paginaInicial" => "823" "paginaFinal" => "834" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30980560" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009900000005/v2_202409130645/S0365059624000783/v2_202409130645/en/main.assets" "Apartado" => array:4 [ "identificador" => "95151" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter - Therapy" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009900000005/v2_202409130645/S0365059624000783/v2_202409130645/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059624000783?idApp=UINPBA00008Z" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 21 | 12 | 33 |
| 2024 Outubro | 391 | 90 | 481 |
| 2024 Setembro | 467 | 146 | 613 |
| 2024 Agosto | 417 | 110 | 527 |
| 2024 Julho | 129 | 96 | 225 |
| 2024 Junho | 100 | 96 | 196 |
| 2024 Maio | 114 | 94 | 208 |
| 2024 Abril | 34 | 42 | 76 |
