Case report
Dyspnea in a nonagenarian: The usual suspects, an unexpected culprit
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array:4 [ "nombre" => "Sérgio" "apellidos" => "Madeira" "email" => array:1 [ 0 => "serg.lou.madeira@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Luís" "apellidos" => "Raposo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Raquel" "apellidos" => "David" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Alexandre" "apellidos" => "Marques" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "José" "apellidos" => "Andrade Gomes" 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"identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1408 "Ancho" => 3006 "Tamanyo" => 214836 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cine-fluoroscopy of percutaneous patent foramen ovale (PFO) closure: (A) device delivery; (B) absence of contrast flow through the septum after PFO closure.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Platypnea-orthodeoxia syndrome (POS) is characterized by dyspnea and hypoxemia induced by orthostatism and relieved by the supine position.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> It is a rare but probably underestimated cause of dyspnea that results from the postural accentuation of an intracardiac or pulmonary right-to-left shunt, leading to arterial oxygen desaturation. The most common etiologic association is an interatrial right-to-left shunt through a patent foramen ovale (PFO) or an atrial septal defect.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Although a right-to-left pressure gradient usually drives the shunt, it can occur in the absence of an elevated right atrial pressure.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2,4</span></a> In the latter cases, embryonic remnants (such as a prominent persistent Eustachian valve or a Chiari network)<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5,6</span></a> or acquired anatomical features (like pulmonary resection, aortic aneurysm, aortic elongation, pericardial effusion, constrictive pericarditis and kyphoscoliosis<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,7</span></a>) can both direct the flow from the inferior vena cava through the fossa ovalis and distort the normal atrial and septal arrangement. Individually or in association, these can create a specific anatomical and functional condition leading to a right-to-left shunt boosted by orthostatism. Although the ultimate underlying mechanisms are unknown, one possibility is that the upright position might stretch the interatrial defect, allowing streaming of systemic venous blood into the left atrium. The treatment of choice is percutaneous closure of the interatrial communication.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 92-year-old woman was admitted to hospital with a left femoral neck fracture caused by a non-syncopal fall at home.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Relevant medical history included hypertension, dyslipidemia, two previous strokes (at the ages of 75 and 82 years) without significant residual motor or cognitive deficits, osteoporosis and severe kyphoscoliosis. She was on treatment with aspirin, simvastatin and losartan. Within the year prior to the admission the patient's family had noticed a progressive functional decline, with undue fatigue and dyspnea for progressively smaller efforts, which were partially relieved by stooping and squatting.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Following admission, hip replacement surgery was undertaken on day 3 of hospital stay, with no relevant complications. During routine early post-surgical observation in the intensive care unit, she was found to be hypoxic when sitting for the first time after the intervention. Physical examination was unremarkable, but interestingly the observed breathlessness and desaturation improved after lying flat and were reproducible on subsequent mobilizations. Blood chemistry, coagulation panel and blood cell count were normal. NT-proBNP level was within the age-adjusted normal range (326 pg/dl). Blood gas analysis, taken in the upright position, showed normal pH and PaCO<span class="elsevierStyleInf">2</span> (7.41 and 42 mmHg, respectively) and reduced PaO<span class="elsevierStyleInf">2</span> (42 mmHg). The chest X-ray revealed a tortuous proximal aorta with clear lung fields. Given the clinical setting, a contrast-enhanced chest computed tomography scan was performed, which excluded both pulmonary embolism and parenchymal lung disease as potential causes. However, severe kyphosis, aortic elongation and a grossly distorted relationship of the aortic root and proximal ascending aorta with the right atrium were noticed (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). A transthoracic echocardiogram showed normal left and right ventricular systolic function and chamber dimensions, mild left ventricular diastolic dysfunction, normal sized atria, no significant valve disease and no signs of pulmonary hypertension (pulmonary artery systolic pressure of 32 mmHg). A bubble contrast study revealed a mild right-to-left atrial shunt in the supine position without Valsalva maneuver, which increased significantly when sitting (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). In order to further assess the relationship between body position and the intensity of the shunt, a tilt-table assisted transesophageal echocardiogram was subsequently performed. While the patient was lying flat, the interatrial septum was redundant and tended to bow towards the left atrium; a small separation of the septum primum and septum secundum was seen, increasing significantly to 4 mm at 45°, unmasking a large shunt by color Doppler flow (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). There was no evidence of embryonic remnants, including a prominent persistent Eustachian valve or a Chiari network. The contrast study confirmed a minimal right-to-left shunt through the PFO while lying flat, which became significantly larger in the semi-upright position (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). During the tilt-table assisted echocardiographic imaging, right and left atrial pressures were studied. Central venous pressure was measured directly in the right atrium through an indwelling jugular catheter, while left atrial pressure was estimated indirectly using the Nagueh formula<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> (taking into account mitral flow velocity by pulsed Doppler and myocardial tissue velocity at the level of the lateral mitral annulus by tissue Doppler imaging on transthoracic echocardiography). A positive right-to-left pressure gradient of 7 mmHg became evident at 45°.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Based on the echocardiographic findings and the 30% decline in arterial partial pressure of oxygen and oxygen saturation in the supine position, a diagnosis of PFO-related POS was established.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Subsequently, the patient underwent percutaneous closure of the PFO with a 25 mm Amplatzer<span class="elsevierStyleSup">®</span> cribriform occluder device (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). The procedure was uneventful, with no evidence of residual right-to-left shunt at the final angiogram. Clinical follow-up has been favorable, with the patient free from breathlessness and desaturation episodes, thus enabling a full functional recovery from hip surgery.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">To our knowledge, this is the oldest patient ever reported in the medical literature diagnosed with PFO-related POS successfully treated by percutaneous closure, with a subsequent full functional recovery from orthopedic surgery, making this case unique.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">POS is an uncommon cause of dyspnea that requires a very high index of suspicion to be recognized; for this reason, it is probably underdiagnosed and its prevalence is likely to be underestimated. It can be associated with cardiac, pulmonary and liver disease,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> but the most common cause is an intracardiac right-to-left shunt, caused by some type of interatrial communication, that is enhanced by orthostatism.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Typically patients have normal pulmonary artery pressure.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">At least two factors must coexist to cause this syndrome: first the presence of an anatomical bypass to the pulmonary circulation, which in the present case was a PFO; second, one or more dynamic factors with a functional impact on intracardiac blood flow patterns – in this case kyphosis and aortic elongation – that can cause or increase the right-to-left shunt in the upright position.</p><p id="par0050" class="elsevierStylePara elsevierViewall">According to case series and anecdotal reports in the literature, most patients are over 60 years old by the time a diagnosis of POS is established.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2,4,11–13</span></a> The most common anatomical interatrial communication is a PFO, followed by true atrial septal defect and fenestrated atrial septal aneurysm.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Contributing factors that have been identified as implicated in the pathogenesis of this condition are pneumectomy, right lower or mid lobe resection, aortic dilatation/elongation, localized or circumferential pericardial effusion, constrictive pericarditis, skeletal deformity (kyphosis, scoliosis) and right diaphragmatic paralysis.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,7,13</span></a> In the majority of cases with a PFO, POS was considered to be the first manifestation of a previously clinically silent PFO that became apparent as a consequence of one or more of the aforementioned conditions, most of which are age-related. Several anatomic and functional changes that occur with aging can create the hemodynamic conditions that facilitate right-to-left shunting through a PFO.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> Progressive increase in PFO size may favor a larger shunt,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> while increased right ventricular stiffness will increase filling and right atrial pressures; aortic dilatation and elongation<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> and thinning of intervertebral discs and vertebral bodies (by accentuating kyphosis)<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> can lead to atrial chamber and/or septal deformation, potentially changing the anatomical relationship between the atrial septum and the inferior vena cava and creating a dynamic right-to-left pressure gradient, that may ultimately be related to respiratory and vascular movements.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the present case, symptoms arose several months before the diagnosis, and a causal relationship to the trauma that determined the initial hospital admission cannot be definitely ruled out. We consider that the effect of an elongated aortic root lying on the top of the right atrium and compressing the chamber and stretching the septum (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>), and severe kyphosis modifying thoracic architecture and thus facilitating abnormal anatomical relationships between intrathoracic structures, are likely to have been contributing or precipitating factors.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Contrast transthoracic echocardiography is the most useful tool for screening right-to-left shunts, in view of its widespread availability, low cost, safety and sensitivity.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> On the other hand, transesophageal echocardiography on the tilt table is better suited for assessing atrial, septal, inferior vena cava and aortic anatomy, as well as the dynamic interactions between these structures and their positional dependency.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> In parallel with imaging, serial positional oxygen measurements should be taken to estimate shunt magnitude. Cardiac catheterization with direct measurement of oxygen saturation in the left atrium and pulmonary veins remains the gold standard for the diagnosis of POS related to intracardiac shunting. However, in daily practice, non-invasive workup is usually sufficient.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The definitive treatment for platypnea-orthodeoxia syndrome related to atrial shunting is closure of the atrial defect.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> The decision to treat should be guided by patient disability rather than shunt magnitude. Percutaneous closure has shown to be effective in patients of all ages,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> avoiding the mortality, morbidity and costs associated with open-heart surgery.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0070" class="elsevierStylePara elsevierViewall">POS is an uncommon and multifaceted phenomenon that should be suspected in the presence of unexplained positional hypoxemia.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Contrast transthoracic echocardiography is a useful screening test when POS is suspected, and the diagnosis can be safely and definitely established by tilt-table transesophageal echocardiography.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Percutaneous closure of a PFO is safe and effective even in nonagenarians with this condition.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres552157" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec569521" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres552156" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec569520" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-10-18" "fechaAceptado" => "2015-01-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec569521" "palabras" => array:5 [ 0 => "Platypnea-orthodeoxia syndrome" 1 => "Tilt table" 2 => "Transesophageal echocardiography" 3 => "Percutaneous closure" 4 => "Patent foramen ovale" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec569520" "palabras" => array:5 [ 0 => "Síndrome platipneia-ortodeoxia" 1 => "Inclinação dinâmica" 2 => "Ecocardiografia transesofágica" 3 => "Encerramento percutâneo" 4 => "<span class="elsevierStyleItalic">Foramen</span> ovale patente" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Platypnea-orthodeoxia syndrome (POS) is an uncommon syndrome characterized by dyspnea and hypoxemia triggered by orthostatism and relieved by recumbency. It is often associated with an interatrial shunt through a patent foramen ovale (PFO). We report the case of a 92-year-old woman initially admitted in the setting of a traumatic femoral neck fracture (successfully treated with hip replacement surgery) in whom a reversible decline in transcutaneous oxygen saturation from 98% (in the supine position) to 84% (in the upright position) was noted early post-operatively. Thoracic multislice computed tomography excluded pulmonary embolism and severe parenchymal lung disease. The diagnosis of POS was confirmed by tilt-table contrast transesophageal echocardiography, which demonstrated a dynamic and position-dependent right-to-left shunt (torrential when semi-upright and minimal in the supine position) through a PFO. The patient underwent percutaneous closure of the PFO with an Amplatzer device, which led to prompt symptom relief and full functional recovery.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A síndrome platipneia-ortodeoxia (SPO) é uma entidade rara caracterizada por dispneia e hipoxemia desencadeadas pelo ortostatismo e aliviadas pelo decúbito. Está frequentemente associada à presença de um <span class="elsevierStyleItalic">shunt</span> inter-auricular através de um <span class="elsevierStyleItalic">foramen</span> ovale patente (FOP). Relata-se o caso de uma mulher de 92 anos, internada inicialmente por fratura traumática do colo do fémur. Foi submetida a artroplastia da anca sem complicações. No período pós operatório inicial observou-se um declínio reversível da saturação de oxigênio de 98% em decúbito dorsal para 84% na posição ortostática. A angio-tomografia computorizada do tórax excluiu trombo-embolia pulmonar e doença grave do parênquima pulmonar. O diagnóstico de SPO foi confirmado por ecocardiografia transesofágica contrastada (soro agitado) com inclinação na mesa de tilt, que demonstrou um <span class="elsevierStyleItalic">shunt</span> direito-esquerdo dinâmico e posicional (torrencial a 45° e mínimo a 0°) através de um FOP. A doente foi submetida a encerramento percutâneo do FOP com dispositivo Amplatzer, que proporcionou alívio sintomático imediato e permitiu uma recuperação funcional total.</p></span>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 833 "Ancho" => 2582 "Tamanyo" => 181779 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Computed tomography: (A) sagittal, (B) coronal and (C) axial views of the thorax.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2842 "Ancho" => 3105 "Tamanyo" => 552708 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiography: (A) upright position with right-to-left shunt after contrast injection in a peripheral vein; (B) supine position, with mild right-to-left shunt seen after contrast injection.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2449 "Ancho" => 3006 "Tamanyo" => 565373 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Tilt-table transesophageal echocardiography: (A) two-dimensional view at 45° unmasking a 4-mm patent foramen ovale (PFO); (B) color Doppler imaging showing a right-to-left shunt through the PFO; (C) bubble study at 0°; (D) bubble study at 45°.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1408 "Ancho" => 3006 "Tamanyo" => 214836 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cine-fluoroscopy of percutaneous patent foramen ovale (PFO) closure: (A) device delivery; (B) absence of contrast flow through the septum after PFO closure.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Platypnea (diffuse zone I phenomenon?)" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 4 | 12 |
| 2024 October | 51 | 41 | 92 |
| 2024 September | 42 | 24 | 66 |
| 2024 August | 56 | 21 | 77 |
| 2024 July | 34 | 29 | 63 |
| 2024 June | 45 | 23 | 68 |
| 2024 May | 35 | 21 | 56 |
| 2024 April | 26 | 30 | 56 |
| 2024 March | 32 | 23 | 55 |
| 2024 February | 33 | 31 | 64 |
| 2024 January | 34 | 32 | 66 |
| 2023 December | 36 | 25 | 61 |
| 2023 November | 48 | 16 | 64 |
| 2023 October | 27 | 15 | 42 |
| 2023 September | 35 | 19 | 54 |
| 2023 August | 27 | 20 | 47 |
| 2023 July | 22 | 6 | 28 |
| 2023 June | 29 | 16 | 45 |
| 2023 May | 46 | 21 | 67 |
| 2023 April | 30 | 5 | 35 |
| 2023 March | 37 | 20 | 57 |
| 2023 February | 25 | 20 | 45 |
| 2023 January | 28 | 6 | 34 |
| 2022 December | 38 | 18 | 56 |
| 2022 November | 37 | 25 | 62 |
| 2022 October | 36 | 15 | 51 |
| 2022 September | 72 | 29 | 101 |
| 2022 August | 40 | 32 | 72 |
| 2022 July | 53 | 30 | 83 |
| 2022 June | 71 | 18 | 89 |
| 2022 May | 48 | 37 | 85 |
| 2022 April | 52 | 25 | 77 |
| 2022 March | 29 | 19 | 48 |
| 2022 February | 36 | 23 | 59 |
| 2022 January | 40 | 29 | 69 |
| 2021 December | 27 | 25 | 52 |
| 2021 November | 42 | 35 | 77 |
| 2021 October | 41 | 41 | 82 |
| 2021 September | 46 | 35 | 81 |
| 2021 August | 59 | 31 | 90 |
| 2021 July | 32 | 34 | 66 |
| 2021 June | 36 | 26 | 62 |
| 2021 May | 45 | 40 | 85 |
| 2021 April | 58 | 39 | 97 |
| 2021 March | 39 | 14 | 53 |
| 2021 February | 45 | 17 | 62 |
| 2021 January | 36 | 7 | 43 |
| 2020 December | 25 | 8 | 33 |
| 2020 November | 27 | 20 | 47 |
| 2020 October | 14 | 7 | 21 |
| 2020 September | 31 | 11 | 42 |
| 2020 August | 17 | 6 | 23 |
| 2020 July | 26 | 6 | 32 |
| 2020 June | 25 | 12 | 37 |
| 2020 May | 30 | 3 | 33 |
| 2020 April | 41 | 18 | 59 |
| 2020 March | 30 | 12 | 42 |
| 2020 February | 43 | 16 | 59 |
| 2020 January | 24 | 5 | 29 |
| 2019 December | 24 | 5 | 29 |
| 2019 November | 24 | 8 | 32 |
| 2019 October | 21 | 11 | 32 |
| 2019 September | 25 | 11 | 36 |
| 2019 August | 20 | 2 | 22 |
| 2019 July | 20 | 11 | 31 |
| 2019 June | 34 | 6 | 40 |
| 2019 May | 24 | 21 | 45 |
| 2019 April | 18 | 14 | 32 |
| 2019 March | 21 | 8 | 29 |
| 2019 February | 28 | 8 | 36 |
| 2019 January | 22 | 8 | 30 |
| 2018 December | 25 | 10 | 35 |
| 2018 November | 68 | 15 | 83 |
| 2018 October | 146 | 19 | 165 |
| 2018 September | 32 | 14 | 46 |
| 2018 August | 23 | 8 | 31 |
| 2018 July | 19 | 5 | 24 |
| 2018 June | 30 | 5 | 35 |
| 2018 May | 40 | 13 | 53 |
| 2018 April | 34 | 5 | 39 |
| 2018 March | 50 | 7 | 57 |
| 2018 February | 29 | 0 | 29 |
| 2018 January | 64 | 12 | 76 |
| 2017 December | 115 | 8 | 123 |
| 2017 November | 34 | 14 | 48 |
| 2017 October | 29 | 8 | 37 |
| 2017 September | 38 | 7 | 45 |
| 2017 August | 28 | 15 | 43 |
| 2017 July | 23 | 11 | 34 |
| 2017 June | 21 | 13 | 34 |
| 2017 May | 27 | 7 | 34 |
| 2017 April | 26 | 5 | 31 |
| 2017 March | 24 | 21 | 45 |
| 2017 February | 23 | 2 | 25 |
| 2017 January | 31 | 5 | 36 |
| 2016 December | 39 | 10 | 49 |
| 2016 November | 23 | 7 | 30 |
| 2016 October | 44 | 5 | 49 |
| 2016 September | 39 | 8 | 47 |
| 2016 August | 13 | 5 | 18 |
| 2016 July | 18 | 7 | 25 |
| 2016 June | 15 | 9 | 24 |
| 2016 May | 7 | 3 | 10 |
| 2016 April | 13 | 1 | 14 |
| 2016 March | 15 | 18 | 33 |
| 2016 February | 32 | 24 | 56 |
| 2016 January | 32 | 18 | 50 |
| 2015 December | 33 | 18 | 51 |
| 2015 November | 25 | 21 | 46 |
| 2015 October | 47 | 34 | 81 |
| 2015 September | 34 | 13 | 47 |
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