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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary artery catheterization is a useful tool for the diagnosis and management of cardiovascular and pulmonary disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> A rupture in a branch of the pulmonary artery is a very rare complication of right heart catheterization using a Swan-Ganz catheter&#59; however&#44; it does have a high mortality rate due to immediate and delayed bleeding following pseudoaneurysm formation&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</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 79-year-old woman with a medical history of atrial fibrillation and rheumatic mitral valve disease underwent closed mitral commissurotomy in 1972&#46; In 2014&#44; the patient had New York Heart Association class III symptoms and moderate mitral stenosis&#44; with a valve area of 1&#46;4 cm<span class="elsevierStyleSup">2</span> by planimetry&#44; and moderate pulmonary hypertension&#46; In order to better assess the pulmonary hypertension&#44; and as part of a planned mitral surgery&#44; elective right heart catheterization via the right femoral vein was performed using a 7F Swan-Ganz pulmonary artery catheter&#46; The patient was under anticoagulation &#40;warfarin&#41; and the procedure was performed with bridging therapy &#40;INR of 1&#46;56 on the day of the procedure&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">During catheterization&#44; after inflation of the balloon tip of the pulmonary artery catheter in the wedge position&#44; she suddenly developed massive hemoptysis and became hypoxic&#46; She was sedated and given aminocaproic acid and vitamin K&#46; The acute bleeding was stopped and the patient was admitted to the coronary care unit&#46; Intubation or mechanical ventilation were not necessary&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A contrast-enhanced computed tomography scan of the chest showed a pulmonary artery pseudoaneurysm with a maximum diameter of 45 mm at the right middle lobe&#44; which was enhanced by contrast &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A and B&#41;&#46; Pulmonary angiography confirmed the diagnosis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A&#41;&#46; After consultations with the respiratory medicine and interventional radiology departments&#44; a percutaneous stent graft implantation was planned&#44; in which a 6F multipurpose guiding catheter &#40;Cordis&#41; was placed and a PT2TM guide wire was positioned distal to the aneurysm&#46; Under angiographic control a 3&#46;5 mm&#215;18 mm stent &#40;BeGraft Peripheral Stent Graft System&#44; Bentley Innomed&#41; was placed in the pulmonary artery&#46; This procedure was successful and there were no complications &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figures 2</a>B and C&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">During hospitalization&#44; the patient was hemodynamically stable and had no further hemoptysis&#46; She was discharged 16 days after admission&#44; treated with aspirin 100 mg&#47;day&#44; clopidogrel 75 mg&#47;day&#44; warfarin 5 mg &#40;dose set by the hematology department&#41;&#44; furosemide 40 mg&#47;day and pantoprazole 20 mg&#47;day&#46; A follow-up chest computed tomography scan performed two months later showed patency of the stent graft in the pulmonary artery&#44; with a completely thrombotic false aneurysm &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; At seven months of follow-up&#44; no events were recorded&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Iatrogenic perforation of a pulmonary artery&#44; followed by pseudoaneurysm formation within minutes or even months&#44; is an uncommon but often catastrophic complication in cases of rupture&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;6</span></a> The reported incidence is between 0&#46;01&#37; and 0&#46;47&#37;&#44; with a mortality rate of 50&#37;&#8211;75&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> A pseudoaneurysm contributes to recurrent hemorrhage in 30&#8211;40&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Risk factors for pulmonary artery rupture include female gender&#44; age over 60 years&#44; pulmonary hypertension&#44; systemic anticoagulation therapy&#44; long-term steroid use&#44; inappropriate catheter placement&#44; peripheral location of the pulmonary artery catheter&#44; surgically induced hypothermia and cardiac manipulation during surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;7</span></a> Our patient had at least three risk factors&#59; the question of inappropriate positioning of the catheter is difficult to assess&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Damage to the arterial wall may be due to the catheter tip being advanced too distally&#44; distal migration of the catheter during balloon deflation&#44; retraction of an inflated balloon&#44; or high-pressure inflation of the balloon in excess of the tensile strength of the vessel wall&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;8&#44;9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Preventive measures to reduce the risk of catheter-induced injury during catheter placement are essential&#44; and include inflating the balloon in a large proximal artery&#59; floating the catheter to its wedge position&#59; minimizing the time in wedge position&#59; avoiding excessive catheter manipulation or balloon hyperinflation&#59; inflation of the catheter balloon with air&#44; not fluids&#59; and deflating the balloon while traction is applied on the catheter&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Catheter-induced injury often affects elderly women and occurs mainly on the right side&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> Hemoptysis is the hallmark symptom&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Clinical presentation may also include hypoxemia&#44; hypotension&#44; bronchospasm&#44; pleural effusion&#44; pneumothorax and hemothorax&#59; however&#44; the patient may remain asymptomatic&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5&#44;8</span></a> Death usually occurs secondary to asphyxia&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Primary management of this injury focuses on the prevention of asphyxia&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> A high level of suspicion&#44; prompt diagnosis and appropriate treatment are essential to avoid mortality&#46; Differential diagnosis includes pulmonary edema&#44; pulmonary infarction&#44; and trauma of the tracheobronchial tree&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Initial measures include provision of adequate oxygenation and minimization of coughing&#44; airway suctioning&#44; and straining&#59; in certain cases lung isolation with selective bronchial intubation may be necessary&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;8</span></a> Before the development of percutaneous endovascular techniques&#44; pulmonary artery pseudoaneurysm would have been treated invasively by surgical lobectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Currently&#44; coil embolization is commonly used as the first-choice treatment&#44; with success in 75&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Embolization also may be performed with n-butyl-cyanoacrylate&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> A successful case was reported using direct injection of thrombin through the distal port of the Swan-Ganz catheter during right heart catheterization&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Stent graft implantation has been described in two previous case reports&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Although the incidence of pulmonary artery perforation by the Swan-Ganz catheter is low&#44; the high potential for rapid mortality makes it essential to be familiar with diagnosis and treatment&#46; Coil embolization is commonly used as the first-choice treatment of pulmonary artery rupture and pseudoaneurysm&#46; This case supports stent graft implantation as an alternative interventional approach for the management of a pulmonary pseudoaneurysm&#46;</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="par0070" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Case report
Massive hemoptysis as an unusual complication of right heart catheterization: Successful treatment with percutaneous stent
Hemoptises massivas como complicação pouco habitual do cateterismo direito: um tratamento bem-sucedido com stent percutâneo
Filipa Melãoa,
Corresponding author
filipamelao@gmail.com

Corresponding author.
, Ricardo Lopesa, Rui André Rodriguesa, Domingos Magalhãesa, Paulo Vilares Morgadob, João Carlos Silvaa, Manuel Campeloa,c, Maria Júlia Maciela
a Serviço de Cardiologia, Centro Hospitalar São João, Porto, Portugal
b Serviço de Radiologia, Centro Hospitalar São João, Porto, Portugal
c Faculdade de Medicina da Universidade do Porto, Portugal
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pulmonary angiogram confirming the presence and location of the pulmonary artery pseudoaneurysm &#40;arrow&#41;&#44; showing its extent&#58; &#40;A&#41; anteroposterior view&#44; with stent graft implantation &#40;arrow&#41; to treat the pseudoaneurysm&#59; &#40;B&#41; anteroposterior view&#44; showing an excellent result with unrestricted blood flow into the periphery when the bleeding had stopped &#40;arrow&#41;&#59; &#40;C&#41; anteroposterior view&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary artery catheterization is a useful tool for the diagnosis and management of cardiovascular and pulmonary disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> A rupture in a branch of the pulmonary artery is a very rare complication of right heart catheterization using a Swan-Ganz catheter&#59; however&#44; it does have a high mortality rate due to immediate and delayed bleeding following pseudoaneurysm formation&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</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 79-year-old woman with a medical history of atrial fibrillation and rheumatic mitral valve disease underwent closed mitral commissurotomy in 1972&#46; In 2014&#44; the patient had New York Heart Association class III symptoms and moderate mitral stenosis&#44; with a valve area of 1&#46;4 cm<span class="elsevierStyleSup">2</span> by planimetry&#44; and moderate pulmonary hypertension&#46; In order to better assess the pulmonary hypertension&#44; and as part of a planned mitral surgery&#44; elective right heart catheterization via the right femoral vein was performed using a 7F Swan-Ganz pulmonary artery catheter&#46; The patient was under anticoagulation &#40;warfarin&#41; and the procedure was performed with bridging therapy &#40;INR of 1&#46;56 on the day of the procedure&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">During catheterization&#44; after inflation of the balloon tip of the pulmonary artery catheter in the wedge position&#44; she suddenly developed massive hemoptysis and became hypoxic&#46; She was sedated and given aminocaproic acid and vitamin K&#46; The acute bleeding was stopped and the patient was admitted to the coronary care unit&#46; Intubation or mechanical ventilation were not necessary&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A contrast-enhanced computed tomography scan of the chest showed a pulmonary artery pseudoaneurysm with a maximum diameter of 45 mm at the right middle lobe&#44; which was enhanced by contrast &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A and B&#41;&#46; Pulmonary angiography confirmed the diagnosis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A&#41;&#46; After consultations with the respiratory medicine and interventional radiology departments&#44; a percutaneous stent graft implantation was planned&#44; in which a 6F multipurpose guiding catheter &#40;Cordis&#41; was placed and a PT2TM guide wire was positioned distal to the aneurysm&#46; Under angiographic control a 3&#46;5 mm&#215;18 mm stent &#40;BeGraft Peripheral Stent Graft System&#44; Bentley Innomed&#41; was placed in the pulmonary artery&#46; This procedure was successful and there were no complications &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figures 2</a>B and C&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">During hospitalization&#44; the patient was hemodynamically stable and had no further hemoptysis&#46; She was discharged 16 days after admission&#44; treated with aspirin 100 mg&#47;day&#44; clopidogrel 75 mg&#47;day&#44; warfarin 5 mg &#40;dose set by the hematology department&#41;&#44; furosemide 40 mg&#47;day and pantoprazole 20 mg&#47;day&#46; A follow-up chest computed tomography scan performed two months later showed patency of the stent graft in the pulmonary artery&#44; with a completely thrombotic false aneurysm &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; At seven months of follow-up&#44; no events were recorded&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Iatrogenic perforation of a pulmonary artery&#44; followed by pseudoaneurysm formation within minutes or even months&#44; is an uncommon but often catastrophic complication in cases of rupture&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;6</span></a> The reported incidence is between 0&#46;01&#37; and 0&#46;47&#37;&#44; with a mortality rate of 50&#37;&#8211;75&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> A pseudoaneurysm contributes to recurrent hemorrhage in 30&#8211;40&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Risk factors for pulmonary artery rupture include female gender&#44; age over 60 years&#44; pulmonary hypertension&#44; systemic anticoagulation therapy&#44; long-term steroid use&#44; inappropriate catheter placement&#44; peripheral location of the pulmonary artery catheter&#44; surgically induced hypothermia and cardiac manipulation during surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;7</span></a> Our patient had at least three risk factors&#59; the question of inappropriate positioning of the catheter is difficult to assess&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Damage to the arterial wall may be due to the catheter tip being advanced too distally&#44; distal migration of the catheter during balloon deflation&#44; retraction of an inflated balloon&#44; or high-pressure inflation of the balloon in excess of the tensile strength of the vessel wall&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;8&#44;9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Preventive measures to reduce the risk of catheter-induced injury during catheter placement are essential&#44; and include inflating the balloon in a large proximal artery&#59; floating the catheter to its wedge position&#59; minimizing the time in wedge position&#59; avoiding excessive catheter manipulation or balloon hyperinflation&#59; inflation of the catheter balloon with air&#44; not fluids&#59; and deflating the balloon while traction is applied on the catheter&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Catheter-induced injury often affects elderly women and occurs mainly on the right side&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> Hemoptysis is the hallmark symptom&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Clinical presentation may also include hypoxemia&#44; hypotension&#44; bronchospasm&#44; pleural effusion&#44; pneumothorax and hemothorax&#59; however&#44; the patient may remain asymptomatic&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5&#44;8</span></a> Death usually occurs secondary to asphyxia&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Primary management of this injury focuses on the prevention of asphyxia&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> A high level of suspicion&#44; prompt diagnosis and appropriate treatment are essential to avoid mortality&#46; Differential diagnosis includes pulmonary edema&#44; pulmonary infarction&#44; and trauma of the tracheobronchial tree&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Initial measures include provision of adequate oxygenation and minimization of coughing&#44; airway suctioning&#44; and straining&#59; in certain cases lung isolation with selective bronchial intubation may be necessary&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;8</span></a> Before the development of percutaneous endovascular techniques&#44; pulmonary artery pseudoaneurysm would have been treated invasively by surgical lobectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Currently&#44; coil embolization is commonly used as the first-choice treatment&#44; with success in 75&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Embolization also may be performed with n-butyl-cyanoacrylate&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> A successful case was reported using direct injection of thrombin through the distal port of the Swan-Ganz catheter during right heart catheterization&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Stent graft implantation has been described in two previous case reports&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Although the incidence of pulmonary artery perforation by the Swan-Ganz catheter is low&#44; the high potential for rapid mortality makes it essential to be familiar with diagnosis and treatment&#46; Coil embolization is commonly used as the first-choice treatment of pulmonary artery rupture and pseudoaneurysm&#46; This case supports stent graft implantation as an alternative interventional approach for the management of a pulmonary pseudoaneurysm&#46;</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="par0070" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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