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devida principalmente a muta&#231;&#245;es com perda de fun&#231;&#227;o no gene que codifica o recetor das lipoprote&#237;nas de baixa densidade &#40;LDLR&#41;&#44; contudo&#44; muta&#231;&#245;es com perda de fun&#231;&#227;o no gene da apolipoprote&#237;na B e muta&#231;&#245;es com ganho de fun&#231;&#227;o no gene da pr&#243;&#8208;prote&#237;na convertase subtilisina&#47;kexina tipo 9 &#40;PCSK9&#41; s&#227;o tamb&#233;m causas&#44; ainda que mais raras&#44; de HF<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">As muta&#231;&#245;es no gene LDLR levam &#224; aus&#234;ncia ou diminui&#231;&#227;o da atividade da prote&#237;na consoante o tipo de muta&#231;&#227;o&#59; as muta&#231;&#245;es no gene da apolipoprote&#237;na B codificam mol&#233;culas de ApoB 100 mutantes&#44; que possuem menor afinidade pelo LDLr impedindo ou diminuindo a liga&#231;&#227;o da ApoB ao LDLr e as muta&#231;&#245;es no gene PCSK9 &#40;muta&#231;&#245;es <span class="elsevierStyleItalic">missense</span>&#41;&#44; aumentam a fun&#231;&#227;o do PCSK9 que codifica uma prote&#237;na que potencia o catabolismo do LDLR<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">A HF homozig&#243;tica &#233; uma doen&#231;a muito rara&#44; com uma preval&#234;ncia de 1 em 1 milh&#227;o de indiv&#237;duos&#46; Na maioria dos casos&#44; quando se refere doentes homozigotos pode tratar&#8208;se de indiv&#237;duos com duas muta&#231;&#245;es funcionais iguais em alelos diferentes &#40;homozig&#243;ticos verdadeiros&#41; ou indiv&#237;duos com duas muta&#231;&#245;es funcionais distintas em alelos diferentes &#40;heterozigotos compostos&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Outra condi&#231;&#227;o rara mas que apresenta o mesmo fen&#243;tipo da HF homozig&#243;tica &#233; a hipercolesterolemia autoss&#243;mica recessiva &#40;HAR&#41;&#46; Nesta patologia muta&#231;&#245;es no gene que codifica para a prote&#237;na adaptadora 1 do LDL&#8208;r &#40;LDLRAP1&#41; s&#227;o a causa da doen&#231;a e os progenitores n&#227;o apresentam em regra dislipidemia<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">H&#225; ainda casos raros de dupla heterozigotia que apresentam um fen&#243;tipo mais grave do que doentes com HF heterozig&#243;tica&#44; mas menos grave do que doentes com HF homozig&#243;tica<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Contrariamente &#224; HF homozig&#243;tica&#44; a HF heterozig&#243;tica tem uma preval&#234;ncia aproximada de um para 300 a um para 500 indiv&#237;duos&#44; tornando&#8208;a numa das doen&#231;as gen&#233;ticas graves mais frequentes&#44; sendo por isso considerada um problema de sa&#250;de p&#250;blica&#44; reconhecido pela Organiza&#231;&#227;o Mundial de Sa&#250;de &#40;OMS&#41;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Prev&#234;&#8208;se que no mundo existam mais de 10 000 000 de indiv&#237;duos com HF&#44; no entanto&#44; menos de 10&#37; est&#227;o diagnosticados e&#44; destes&#44; menos de 25&#37; recebem tratamento hipolipemiante<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">O tratamento da dislipidemia&#44; tanto em preven&#231;&#227;o prim&#225;ria como secund&#225;ria&#44; tem&#8208;se centrado na redu&#231;&#227;o do LDL&#8208;c&#46; Numerosos ensaios cl&#237;nicos demonstraram o benef&#237;cio da diminui&#231;&#227;o do LDL&#8208;c com estatinas na redu&#231;&#227;o da morbilidade e mortalidade cardiovascular&#44; tornando o LDL&#8208;c o alvo principal a atingir de modo a diminuir o risco de eventos cardiovasculares<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;14</span></a>&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Em doentes com hipercolesterolemia grave que s&#227;o intolerantes ou resistentes &#224; terap&#234;utica institu&#237;da&#44; entre outras op&#231;&#245;es de tratamento n&#227;o farmacol&#243;gico inclui&#8208;se a LDL&#8208;af&#233;rese&#46; H&#225; v&#225;rias t&#233;cnicas de LDL&#8208;af&#233;rese dispon&#237;veis&#46; Todas elas mostram uma redu&#231;&#227;o significativa e aguda dos n&#237;veis plasm&#225;ticos de LDL&#8208;c<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46; No Hospital Santo Ant&#243;nio &#8211; Centro Hospitalar do Porto &#40;HSA &#8211; CHP&#41; usamos a t&#233;cnica de adsor&#231;&#227;o direta de lipoprote&#237;nas &#40;DALI&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Objetivo</span><p id="par0195" class="elsevierStylePara elsevierViewall">Apresentar a experi&#234;ncia da Consulta Multidisciplinar de Dislipidemias na avalia&#231;&#227;o de doentes com hipercolesterolemia grave resistente &#224; terap&#234;utica institu&#237;da&#44; submetidos ao tratamento com LDL&#8208;af&#233;rese pela t&#233;cnica DALI&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Material e m&#233;todos</span><p id="par0200" class="elsevierStylePara elsevierViewall">O Servi&#231;o de Endocrinologia do HSA &#8211; CHP tem desde 1993 uma Consulta Multidisciplinar de Dislipidemias que engloba as especialidades de endocrinologia e nutri&#231;&#227;o e possui um protocolo de trabalho com as especialidades de cardiologia&#44; neurologia&#44; qu&#237;mica cl&#237;nica e nefrologia&#46; Com uma periodicidade semanal&#44; o principal objetivo desta consulta &#233; o estudo e tratamento de dislipidemias graves&#44; dispondo desde 2008 de LDL&#8208;af&#233;rese pela t&#233;cnica de DALI&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Adsor&#231;&#227;o direta de lipoprote&#237;nas</span><p id="par0205" class="elsevierStylePara elsevierViewall">Nesta t&#233;cnica&#44; o sangue total &#40;sem separa&#231;&#227;o do plasma&#41; passa atrav&#233;s de uma coluna adsorvente contendo gel de poliacrilamida&#44; que &#233; constitu&#237;do por poli&#8208;ani&#245;es com grupos carboxilo carregados negativamente&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Os poli&#8208;ani&#245;es interatuam seletivamente com os grupos cati&#243;nicos da Apo B que se encontra nas lipoprote&#237;nas de muito baixa densidade &#40;VLDL&#41;&#44; nas lipoprote&#237;nas de densidade interm&#233;dia &#40;IDL&#41;&#44; nas lipoprote&#237;nas de baixa densidade &#40;LDL&#41; e na lipoprote&#237;na &#40;a&#41; &#40;Lp&#40;a&#41;&#41;&#46; Cada uma destas lipoprote&#237;nas cont&#233;m uma &#250;nica mol&#233;cula de Apo B&#44; atrav&#233;s da qual as lipoprote&#237;nas ficam imobilizadas na coluna adsorvente por intera&#231;&#245;es eletroqu&#237;micas&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">As lipoprote&#237;nas de alta densidade &#40;HDL&#41;&#44; devido ao seu revestimento em ApoA1&#44; n&#227;o interatuam com os poli&#8208;ani&#245;es da coluna adsorvente e portanto n&#227;o s&#227;o eliminadas pela t&#233;cnica&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Ap&#243;s passar pela coluna adsorvente&#44; o sangue depletado de ApoB&#44; retorna ao doente&#44; verificando&#8208;se uma redu&#231;&#227;o do LDL&#8208;c superior a 60&#37;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a>&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">As sess&#245;es de af&#233;rese s&#227;o realizadas com o seguinte equipamento da Fresenius Medical Care&#44; Alemanha&#58; monitor 4008 ADS&#44; colunas adsorventes DALI&#44; solu&#231;&#227;o <span class="elsevierStyleItalic">priming</span> e solu&#231;&#227;o de &#225;cido c&#237;trico em dextrose f&#243;rmula A &#40;ACD&#8208;A&#41;&#46; De acordo com as <span class="elsevierStyleItalic">guidelines</span> alem&#227;s de boa pr&#225;tica cl&#237;nica&#44; o objetivo da LDL&#8208;af&#233;rese &#233; a obten&#231;&#227;o de uma redu&#231;&#227;o de LDL&#8208;c&#44; por sess&#227;o&#44; superior ou igual a 60&#37;&#44; para o que dispomos de duas configura&#231;&#245;es de colunas&#58; DALI&#8208;750 e DALI&#8208;1&#46;000<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Nos doentes com indica&#231;&#227;o para utiliza&#231;&#227;o prolongada ou cr&#243;nica deste tratamento sugere&#8208;se a realiza&#231;&#227;o de uma f&#237;stula arteriovenosa&#44; com o objetivo de facilitar os acessos vasculares e&#44; consequentemente&#44; o procedimento&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">O volume de sangue processado por sess&#227;o &#233; individualizado dependendo do sexo e peso do doente e a velocidade de perfus&#227;o varia de 60 a 100<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">A proposta de um doente para a realiza&#231;&#227;o deste tratamento obedece a uma posi&#231;&#227;o de consenso da equipa multidisciplinar&#46; Como crit&#233;rios de sele&#231;&#227;o para a realiza&#231;&#227;o de LDL&#8208;af&#233;rese usamos as recomenda&#231;&#245;es da <span class="elsevierStyleItalic">Food and Drug Administration</span> &#40;FDA&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0245" class="elsevierStylePara elsevierViewall">Em doentes nos quais&#44; ap&#243;s seis meses de terap&#234;utica n&#227;o farmacol&#243;gica e farmacol&#243;gica na dose m&#225;xima tolerada&#44; n&#227;o forem alcan&#231;ados os alvos terap&#234;uticos&#44; recomenda&#8208;se a LDL&#8208;af&#233;rese de acordo com as indica&#231;&#245;es pr&#233;vias&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">M&#233;todos laboratoriais</span><p id="par0250" class="elsevierStylePara elsevierViewall">O estudo anal&#237;tico &#233; realizado no Servi&#231;o de Qu&#237;mica Cl&#237;nica do HSA &#8211; CHP pelo equipamento Cobas Integra 800 &#40;Roche diagnostics GmbH&#44; Germany&#46; D&#8208;68298 Mannheim&#44; Alemanha&#41; com reagentes pr&#243;prios&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">As amostras de sangue s&#227;o obtidas diretamente a partir do acesso aferente&#44; imediatamente antes do in&#237;cio da sess&#227;o&#46; As colheitas ap&#243;s a sess&#227;o s&#227;o efetuadas no final do tratamento&#44; antes da reinfus&#227;o do circuito extracorporal por solu&#231;&#227;o salina&#44; atrav&#233;s do mesmo acesso&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">C&#225;lculos</span><p id="par0260" class="elsevierStylePara elsevierViewall">A redu&#231;&#227;o aguda de cada par&#226;metro lip&#237;dico &#40;PL&#41;&#44; num &#250;nico tratamento&#44; &#233; calculada a partir da concentra&#231;&#227;o do mesmo de antes &#40;PL pr&#233;&#41; e ap&#243;s &#40;PL ap&#243;s&#41; a sess&#227;o&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">&#37; Redu&#231;&#227;o aguda do PL<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>x &#40;PL pr&#233; &#8208; PL p&#243;s&#41;&#47;PL pr&#233;</p><p id="par0270" class="elsevierStylePara elsevierViewall">A redu&#231;&#227;o a longo prazo de cada PL &#233; calculada a partir da sua concentra&#231;&#227;o basal &#40;PL basal&#41;&#44; isto &#233;&#44; pr&#233;via &#224; primeira sess&#227;o&#44; e da m&#233;dia da concentra&#231;&#227;o do PL &#40;PL m&#233;dio&#41; depois da antepen&#250;ltima sess&#227;o &#40;PL p&#243;s &#40;n&#8208;2&#41;&#41;&#44; antes da pen&#250;ltima sess&#227;o &#40;PL pr&#233; &#40;n&#8208;1&#41;&#41;&#44; depois da pen&#250;ltima sess&#227;o &#40;PL p&#243;s &#40;n&#8208;1&#41;&#41; e antes da &#250;ltima sess&#227;o &#40;PL pr&#233; &#40;n&#41;&#41;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;20</span></a>&#58;<elsevierMultimedia ident="eq0005"></elsevierMultimedia><elsevierMultimedia ident="eq0010"></elsevierMultimedia></p><p id="par0285" class="elsevierStylePara elsevierViewall">Nota&#58; &#40;n&#8208;2&#41;&#44; &#40;n&#8208;1&#41; e &#40;n&#41; refere&#8208;se &#224;s tr&#234;s &#250;ltimas sess&#245;es&#44; por ordem cronol&#243;gica&#44; da mais antiga para a mais recente&#44; respetivamente&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">As mesmas f&#243;rmulas foram utilizadas para todos os PL&#58; LDL&#8208;c&#44; triglicer&#237;deos &#40;TG&#41;&#44; colesterol total &#40;CT&#41;&#44; colesterol de lipoprote&#237;nas de elevada densidade &#40;HDL&#8208;c&#41; e colesterol n&#227;o HDL &#40;nHDL&#8208;c&#41;&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">O nHDL&#8208;c calcula&#8208;se atrav&#233;s da diferen&#231;a entre o CT e o HDL&#8208;c&#58;<elsevierMultimedia ident="eq0015"></elsevierMultimedia></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Resultados</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Pacientes envolvidos</span><p id="par0305" class="elsevierStylePara elsevierViewall">Todos os doentes foram submetidos a LDL&#8208;af&#233;rese pela t&#233;cnica DALI&#44; com periodicidade quinzenal&#44; mantendo toda a terap&#234;utica farmacol&#243;gica previamente institu&#237;da&#46; Cada sess&#227;o teve uma dura&#231;&#227;o m&#233;dia de 90 minutos&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Doente 1</span><p id="par0310" class="elsevierStylePara elsevierViewall">Sexo masculino&#44; 55 anos&#44; cardiopatia isqu&#233;mica assintom&#225;tica&#44; diagnosticada aos 37 anos em prova de esfor&#231;o&#44; estenose cr&#237;tica da art&#233;ria coron&#225;ria direita&#44; coloca&#231;&#227;o de <span class="elsevierStyleItalic">stent</span> em 1995&#44; reestenose da mesma em 2010 com coloca&#231;&#227;o de mais dois <span class="elsevierStyleItalic">stents</span>&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Sem h&#225;bitos tab&#225;gicos&#44; sem outros fatores de risco cardiovascular &#40;FRCV&#41; como diabetes <span class="elsevierStyleItalic">mellitus</span> &#40;DM&#41;&#44; hipertens&#227;o arterial &#40;HTA&#41;&#44; hist&#243;ria de doen&#231;a card&#237;aca isqu&#233;mica familiar precoce ou de dislipidemia familiar e sem excesso de peso ou obesidade&#44; com &#237;ndice de massa corporal &#40;IMC&#41; de 23&#44;8<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">Perfil lip&#237;dico pr&#233;&#8208;tratamento&#58; CT &#8211; 390<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; TG &#8211; 140<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; HDL&#8208;c &#8211; 50<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; LDL&#8208;c &#8211; 312<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; Apo A1 &#8211; 109<span class="elsevierStyleHsp" style=""></span>mg&#47;dl e Apo B &#8211; 186<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Restante estudo anal&#237;tico sem altera&#231;&#245;es&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Por apresentar eleva&#231;&#227;o sustentada das transaminases com rosuvastatina na dose de 40<span class="elsevierStyleHsp" style=""></span>mg&#47;dia&#44; intoler&#226;ncia &#224;s resinas manifestada por obstipa&#231;&#227;o e exuberante <span class="elsevierStyleItalic">flushing</span> com o &#225;cido nicot&#237;nico&#44; o doente estava medicado com rosuvastatina 20<span class="elsevierStyleHsp" style=""></span>mg&#47;dia &#40;dose m&#225;xima tolerada&#41; e ezetimibe 10<span class="elsevierStyleHsp" style=""></span>mg&#47;dia&#46; Adicionalmente&#44; tomava diltiazem 120<span class="elsevierStyleHsp" style=""></span>mg&#44; clopidogrel 75<span class="elsevierStyleHsp" style=""></span>mg e aspirina 100<span class="elsevierStyleHsp" style=""></span>mg&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Apresentava&#44; portanto&#44; dislipidemia refrat&#225;ria &#224; terap&#234;utica farmacol&#243;gica tolerada&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">O estudo gen&#233;tico mostrou a presen&#231;a de uma muta&#231;&#227;o funcional em heterozigotia no gene PCSK9&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Iniciou LDL&#8208;af&#233;rese em dezembro de 2008 com filtro de 750&#44; como terap&#234;utica coadjuvante&#44; isto &#233;&#44; mantendo a terap&#234;utica hipolipemiante habitual&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">Quatro anos ap&#243;s o in&#237;cio da LDL&#8208;af&#233;rese&#58; ecoDoppler carot&#237;deo revela doen&#231;a ateroscler&#243;tica carot&#237;dea difusa com estenose ligeira &#40;estenose do l&#250;men<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20&#37;&#41; das art&#233;rias car&#243;tidas internas direita e esquerda&#59; estudo de perfus&#227;o do mioc&#225;rdio sem evid&#234;ncia de isquemia&#44; defeito fixo ligeiro &#237;nfero&#8208;lateral e boa fun&#231;&#227;o sist&#243;lica global do ventr&#237;culo esquerdo&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Doente 2</span><p id="par0350" class="elsevierStylePara elsevierViewall">Sexo masculino&#44; 59 anos&#44; dislipidemia grave diagnosticada aos 36 anos em an&#225;lises de rotina&#59; presen&#231;a de xantelasmas e xantomas tendinosos&#59; doen&#231;a ateroscler&#243;tica carot&#237;dea assintom&#225;tica&#44; estenose superior a 70&#37; da art&#233;ria car&#243;tida interna direita e estenose de 50&#8208;70&#37; da art&#233;ria car&#243;tida interna esquerda&#44; submetido a endarterectomia programada da art&#233;ria car&#243;tida interna direita em mar&#231;o de 2007&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">Ex&#8208;fumador&#44; normoponderal &#40;IMC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#44;8<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; antecedentes de dislipidemia familiar &#8211; m&#227;e&#44; irm&#227;os e filha com hipercolesterolemia&#44; sem outros FRCV&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">Perfil lip&#237;dico pr&#233;&#8208;tratamento&#58; CT &#8211; 378<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; TG &#8211; 75<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; HDL&#8208;c &#8211; 112<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; LDL&#8208;c &#8211; 251<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; Apo A1 &#8211; 223<span class="elsevierStyleHsp" style=""></span>mg&#47;dl e Apo B &#8211; 176<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Restante estudo anal&#237;tico sem altera&#231;&#245;es&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Por apresentar mialgias com rosuvastatina na dose de 40<span class="elsevierStyleHsp" style=""></span>mg&#47;dia&#44; intoler&#226;ncia &#224;s resinas para as doses m&#225;ximas recomendadas e exacerba&#231;&#227;o da patologia g&#225;strica &#40;&#250;lcera p&#233;ptica&#41; com o &#225;cido nicot&#237;nico&#44; o doente estava medicado com colestiramina 8<span class="elsevierStyleHsp" style=""></span>g&#47;dia&#44; rosuvastatina 20<span class="elsevierStyleHsp" style=""></span>mg&#47;dia e ezetimibe 10<span class="elsevierStyleHsp" style=""></span>mg&#47;dia&#44; para al&#233;m de &#225;cido acetilsalic&#237;lico 325<span class="elsevierStyleHsp" style=""></span>mg&#44; valsartan 160<span class="elsevierStyleHsp" style=""></span>mg e esomeprazol 40<span class="elsevierStyleHsp" style=""></span>mg&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">O estudo gen&#233;tico mostrou a presen&#231;a de uma muta&#231;&#227;o funcional em heterozigotia no gene LDLR&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall">Iniciou LDL&#8208;af&#233;rese em mar&#231;o de 2009 com filtro de 750&#44; mantendo a terap&#234;utica hipolipemiante pr&#233;via&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">Aproximadamente quatro anos depois do in&#237;cio da LDL&#8208;af&#233;rese&#58; o ecoDoppler carot&#237;deo revela doen&#231;a ateroscler&#243;tica difusa com estenose ligeira da art&#233;ria car&#243;tida interna direita&#44; que condiciona estenose do l&#250;men inferior a 20&#37; e estenose moderada da art&#233;ria car&#243;tida interna esquerda&#44; com placa de ateroma ecog&#233;nica parcialmente calcificada que condiciona estenose de 30&#8208;50&#37; do l&#250;men&#44; fluxo carot&#237;deo com caracter&#237;sticas normais&#59; as altera&#231;&#245;es observadas no estudo de perfus&#227;o do mioc&#225;rdio s&#227;o compat&#237;veis com isquemia discreta em territ&#243;rio da art&#233;ria descendente anterior&#44; boa fun&#231;&#227;o sist&#243;lica global do ventr&#237;culo esquerdo&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Doente 3</span><p id="par0385" class="elsevierStylePara elsevierViewall">Sexo feminino&#44; 62 anos&#44; estenose a&#243;rtica severa&#44; sintom&#225;tica&#44; submetida a substitui&#231;&#227;o da v&#225;lvula a&#243;rtica por pr&#243;tese mec&#226;nica em julho de 2010&#46; Doen&#231;a arterioscler&#243;tica carot&#237;dea assintom&#225;tica&#44; ateromas nas art&#233;rias car&#243;tidas comuns e in&#237;cio das art&#233;rias car&#243;tidas internas com estenose inferior a 30&#37;&#46;</p><p id="par0390" class="elsevierStylePara elsevierViewall">Antecedentes de dislipidemia familiar &#8211; filha e neto com hipercolesterolemia&#44; normoponderal &#40;IMC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#44;7<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; sem outros FRCV&#44; nomeadamente&#44; n&#227;o fumadora&#44; sem HTA&#44; sem DM&#44; sem hist&#243;ria de doen&#231;a cardiovascular precoce&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">Perfil lip&#237;dico pr&#233;&#8208;tratamento&#58; CT &#8211; 379<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; TG &#8211; 71<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; HDL&#8208;c &#8211; 67<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; LDL&#8208;c &#8211; 298<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; Apo A1 &#8211; 120<span class="elsevierStyleHsp" style=""></span>mg&#47;dl e Apo B &#8211; 184<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Restante estudo anal&#237;tico sem altera&#231;&#245;es&#46;</p><p id="par0400" class="elsevierStylePara elsevierViewall">Por n&#227;o tolerar rosuvastatina na dose de 40<span class="elsevierStyleHsp" style=""></span>mg nem resinas&#44; estava medicada com rosuvastatina 20<span class="elsevierStyleHsp" style=""></span>mg&#44; &#225;cido nicot&#237;nico 1<span class="elsevierStyleHsp" style=""></span>g &#40;dose m&#225;xima tolerada pela doente&#41;&#44; ezetimibe 10<span class="elsevierStyleHsp" style=""></span>mg&#44; varfarina 5<span class="elsevierStyleHsp" style=""></span>mg&#44; aspirina 100<span class="elsevierStyleHsp" style=""></span>mg e diazepam 5<span class="elsevierStyleHsp" style=""></span>mg&#46;</p><p id="par0405" class="elsevierStylePara elsevierViewall">O estudo gen&#233;tico mostrou a presen&#231;a de uma muta&#231;&#227;o funcional em heterozigotia no gene LDLR e outra altera&#231;&#227;o com funcionalidade desconhecida no gene LDLR&#46; Estudos funcionais est&#227;o a ser realizados para comprovar a patogenicidade desta altera&#231;&#227;o&#59; no caso de esta ser verificada&#44; a doente ser&#225; classificada como heterozigota composta&#46;</p><p id="par0410" class="elsevierStylePara elsevierViewall">Iniciou LDL&#8208;af&#233;rese em mar&#231;o de 2009&#44; mantendo a terap&#234;utica hipolipemante habitual&#46; Come&#231;ou com filtro de 750 e por aus&#234;ncia de resposta adequada passou para o filtro de 1000<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0415" class="elsevierStylePara elsevierViewall">Aproximadamente quatro anos depois do in&#237;cio da LDL&#8208;af&#233;rese&#58; o ecoDoppler carot&#237;deo revela ateroma regular na art&#233;ria car&#243;tida interna direita com estenose<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30&#37; e na art&#233;ria car&#243;tida interna esquerda com estenose<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20&#37;&#59; estudo de perfus&#227;o do mioc&#225;rdio dentro dos padr&#245;es da normalidade&#46; Boa fun&#231;&#227;o sist&#243;lica global do ventr&#237;culo esquerdo&#46;</p><p id="par0420" class="elsevierStylePara elsevierViewall">Entre dezembro de 2008 e janeiro de 2013 foram efetuados 308 tratamentos &#40;<a class="elsevierStyleCrossRefs" href="#tbl0010">Tabelas 2&#8211;6</a>&#41;&#46; Durante todas estas sess&#245;es de LDL&#8208;af&#233;rese houve 11 intercorr&#234;ncias &#8211; dez <span class="elsevierStyleItalic">minor</span> e uma <span class="elsevierStyleItalic">major</span> &#8211; das quais&#44; seis epis&#243;dios de dor precordial&#44; tr&#234;s casos de hipotens&#227;o arterial&#44; um acompanhado por uma rea&#231;&#227;o anafil&#225;tica&#44; e um epis&#243;dio de coagula&#231;&#227;o do circuito extracorporal&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discuss&#227;o</span><p id="par0425" class="elsevierStylePara elsevierViewall">Cerca de 96&#44;4&#37; das sess&#245;es decorreram sem quaisquer intercorr&#234;ncias&#44; um valor id&#234;ntico ao descrito na literatura<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a>&#46; A incid&#234;ncia global de efeitos adversos durante as sess&#245;es foi de 3&#44;6&#37;&#44; um valor tamb&#233;m id&#234;ntico ao descrito por outros autores e havendo necessidade de interromper o tratamento apenas num caso<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a>&#46; Em nenhum doente se registaram efeitos adversos prolongados ou irrevers&#237;veis&#46;</p><p id="par0430" class="elsevierStylePara elsevierViewall">Comparando os efeitos adversos dos nossos doentes com os observados no estudo <span class="elsevierStyleItalic">Direct Adsorption of Low&#8208;Density Lipoprotein By DALI&#8208;Apheresis&#58; Results of a Prospective Long&#8208;term Multicenter Follow&#8208;up Covering 12291 sessions</span>&#44; verificamos que nos nossos doentes os efeitos adversos mais frequentes foram a dor anginosa &#40;1&#44;95 <span class="elsevierStyleItalic">versus</span> 0&#44;09&#37;&#41;&#44; seguida de hipotens&#227;o arterial &#40;0&#44;97 <span class="elsevierStyleItalic">versus</span> 0&#44;97&#37;&#41;&#44; coagula&#231;&#227;o do circuito extracorporal &#40;0&#44;32 <span class="elsevierStyleItalic">versus</span> 0&#44;03&#37;&#41; e uma rea&#231;&#227;o anafil&#225;tica &#40;0&#44;32 <span class="elsevierStyleItalic">versus</span> 0&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a>&#46;</p><p id="par0435" class="elsevierStylePara elsevierViewall">Durante as 308 sess&#245;es de LDL&#8208;af&#233;rese houve seis epis&#243;dios de angina de peito&#44; uma percentagem mais elevada que a descrita na literatura<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a>&#46; Todos estes epis&#243;dios ocorreram na mesma doente&#44; que apresentava estenose cr&#237;tica da v&#225;lvula a&#243;rtica e reverteram com a lentifica&#231;&#227;o do fluxo sangu&#237;neo&#44; fluidoterapia&#44; oxigenoterapia e administra&#231;&#227;o de nitratos&#46; A etiologia da dor anginosa ser&#225; provavelmente multifatorial&#44; mas pensamos que a doen&#231;a subjacente&#44; estenose a&#243;rtica&#44; teve um papel preponderante uma vez que ap&#243;s tratamento cir&#250;rgico n&#227;o houve refer&#234;ncia a novos epis&#243;dios de angor&#46;</p><p id="par0440" class="elsevierStylePara elsevierViewall">A hipotens&#227;o &#233; descrita como a complica&#231;&#227;o mais frequente na LDL&#8208;af&#233;rese<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;20&#44;21</span></a>&#46; Esta pode ser devida a hipovolemia&#44; vasodilata&#231;&#227;o ou rea&#231;&#227;o vasovagal&#46; Sabemos que na t&#233;cnica DALI as superf&#237;cies das colunas carregadas negativamente aumentam a concentra&#231;&#227;o de fator <span class="elsevierStyleSmallCaps">XII</span>&#44; kalikre&#237;na e bradicinina&#46; A bradicinina pode provocar hipotens&#227;o&#44; <span class="elsevierStyleItalic">flushing</span> e edema de Quincke&#46; Apesar de ser gerada na coluna adsorvente e reinfundida no paciente&#44; &#233; rapidamente degradada sistemicamente pela a&#231;&#227;o da enzima conversora da angiotensina &#40;ECA&#41;&#44; pelo que os n&#237;veis de bradicinina na linha aferente pr&#233;&#8208;adsorvente s&#227;o praticamente negligenci&#225;veis<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;22</span></a>&#46;</p><p id="par0445" class="elsevierStylePara elsevierViewall">A principal causa de hipovolemia verificada na t&#233;cnica DALI parece ser a transfer&#234;ncia inicial de sangue para o circuito extracorporal&#46; Para minimizar este efeito e prevenir a hipotens&#227;o&#44; tal como alguns autores&#44; substitu&#237;mos parte do volume inicial de sangue por uma infus&#227;o salina na veia contralateral&#44; enquanto o circuito extracorporal &#233; preenchido com sangue<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0450" class="elsevierStylePara elsevierViewall">Dos tr&#234;s epis&#243;dios hipotensivos referidos&#44; um foi mais grave e acompanhado de palidez&#44; dispneia e sensa&#231;&#227;o de morte iminente&#44; ocorrendo num doente a quem foi prescrito pela primeira vez ramipril e o tomou inadvertidamente&#44; no dia da sess&#227;o de LDL&#8208;af&#233;rese&#46; Este epis&#243;dio foi por n&#243;s interpretado como uma rea&#231;&#227;o anafil&#225;tica&#46; A t&#233;cnica de DALI pode causar hipotens&#227;o grave em doentes que tomam inibidores da enzima conversora da angiotensina &#40;IECA&#41;&#44; devido &#224; diminui&#231;&#227;o do catabolismo da bradicinina causado por inibi&#231;&#227;o da ECA e ao aumento da produ&#231;&#227;o de bradicinina que surge durante o procedimento&#44; pelo que os f&#225;rmacos que bloqueiam a degrada&#231;&#227;o de bradicinina em metabolitos inativos est&#227;o contraindicados em doentes sob LDL&#8208;af&#233;rese pela t&#233;cnica DALI<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">21&#44;23</span></a>&#46;</p><p id="par0455" class="elsevierStylePara elsevierViewall">Para evitar o risco de hipotens&#227;o nos doentes submetidos &#224; t&#233;cnica DALI&#44; os IECA devem ser suspensos 24 horas antes do tratamento e&#44; sempre que poss&#237;vel&#44; substitu&#237;dos por outros f&#225;rmacos anti&#8208;hipertensores&#44; incluindo os bloqueadores do recetor da angiotensina que n&#227;o inibem a ECA e&#44; portanto&#44; podem ser prescritos&#46;</p><p id="par0460" class="elsevierStylePara elsevierViewall">Dos tr&#234;s casos de hipotens&#227;o descritos&#44; dois resolveram com fluidoterapia EV e lentifica&#231;&#227;o do fluxo sangu&#237;neo&#59; na situa&#231;&#227;o mais grave a LDL&#8208;af&#233;rese foi suspensa e foi necess&#225;rio oxigenoterapia&#44; fluidoterapia e corticoterapia por via endovenosa&#46;</p><p id="par0465" class="elsevierStylePara elsevierViewall">Para prevenir a forma&#231;&#227;o do co&#225;gulo no circuito da af&#233;rese&#44; tal como descrito na literatura&#44; usamos o citrato como anticoagulante&#44; 1<span class="elsevierStyleHsp" style=""></span>ml de &#225;cido c&#237;trico em dextrose por 20&#8208;40<span class="elsevierStyleHsp" style=""></span>ml de sangue&#44; que se revela suficiente para adequada anticoagula&#231;&#227;o do circuito extracorporal<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">20&#44;21</span></a>&#46; Em 308 sess&#245;es tivemos um epis&#243;dio de coagula&#231;&#227;o do circuito extracorporal &#40;0&#44;32 <span class="elsevierStyleItalic">versus</span> 0&#44;17&#37;&#41;&#46;</p><p id="par0470" class="elsevierStylePara elsevierViewall">Para al&#233;m das lipoprote&#237;nas&#44; a coluna adsorvente do sistema DALI tamb&#233;m adsorve os i&#245;es carregados positivamente como o c&#225;lcio e o magn&#233;sio&#46; Na nossa experi&#234;ncia n&#227;o tivemos hipocalcemia nem hipomagnesemia&#46; Como outros autores&#44; pensamos que tal possa ser justificado pelo uso de uma solu&#231;&#227;o <span class="elsevierStyleItalic">priming</span> que cont&#233;m estes eletr&#243;litos e que vai saturar a coluna com estes cati&#245;es de modo a prevenir a hipocalcemia e a hipomagnesemia durante o tratamento&#59; e tamb&#233;m pelo uso profil&#225;tico de uma ampola de gluconato de c&#225;lcio no final de cada sess&#227;o<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0475" class="elsevierStylePara elsevierViewall">Nos doentes tratados cronicamente com LDL&#8208;af&#233;rese est&#225; tamb&#233;m descrita defici&#234;ncia de ferro e&#44; consequentemente&#44; anemia microc&#237;tica&#46; A ferropenia verificada pode ser devida aos estudos anal&#237;ticos frequentes e &#224; perda residual de sangue no circuito extracorporal ap&#243;s a sess&#227;o&#46; Nos nossos doentes n&#227;o se verificou ferropenia&#44; nem anemia&#46;</p><p id="par0480" class="elsevierStylePara elsevierViewall">Para avalia&#231;&#227;o da efic&#225;cia da t&#233;cnica a n&#237;vel dos par&#226;metros lip&#237;dicos usamos a metodologia j&#225; referida por alguns autores e previamente descrita por n&#243;s<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;20</span></a>&#46;</p><p id="par0485" class="elsevierStylePara elsevierViewall">Assim&#44; obtivemos redu&#231;&#245;es agudas m&#233;dias do LDL&#8208;c da ordem dos 63&#44;3&#37; &#40;m&#237;nimo de 57&#44;3&#37; e m&#225;ximo de 69&#44;6&#37;&#41;&#44; resultado id&#234;ntico ao verificado por outros autores e que atinge os objetivos das <span class="elsevierStyleItalic">guidelines</span> alem&#227;s de boa pr&#225;tica cl&#237;nica na LDL&#8208;af&#233;rese<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;21</span></a>&#46;</p><p id="par0490" class="elsevierStylePara elsevierViewall">Relativamente &#224;s redu&#231;&#245;es a longo prazo do LDL&#8208;c&#44; obtivemos uma redu&#231;&#227;o m&#233;dia de 36&#44;0&#37; &#40;m&#237;nimo de 25&#44;6&#37; e m&#225;ximo de 44&#44;2&#37;&#41;&#44; um resultado ligeiramente inferior ao descrito na literatura&#44; todavia acreditamos que esta diferen&#231;a possa ser justificada pelo maior tempo de tratamento&#44; maior n&#250;mero de doentes envolvidos e&#44; tamb&#233;m&#44; pela maior ades&#227;o do doente &#224; terap&#234;utica farmacol&#243;gica&#44; no caso dos estudos referidos<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a>&#46;</p><p id="par0495" class="elsevierStylePara elsevierViewall">Obtivemos redu&#231;&#245;es agudas m&#233;dias do nHDL&#8208;c da ordem dos 62&#44;3&#37; &#40;m&#237;nimo de 55&#44;1&#37; e m&#225;ximo de 68&#44;4&#37;&#41; e redu&#231;&#245;es a longo prazo do nHDL&#8208;c m&#233;dias de 35&#44;5&#37; &#40;m&#237;nimo de 23&#44;9&#37; e m&#225;ximo de 45&#44;4&#37;&#41;&#46; Estas redu&#231;&#245;es no nHDL&#8208;c foram sobrepon&#237;veis &#224;s do LDL&#8208;c&#46; Pensamos que este dado se deve &#224;s caracter&#237;sticas da dislipidemia dos doentes estudados&#58; hipercolesterolemia&#44; sem DM&#44; sem obesidade e sem crit&#233;rios de s&#237;ndrome metab&#243;lica&#44; portanto&#44; sem fatores que promovam a produ&#231;&#227;o de part&#237;culas VLDL e IDL&#46; Por outro lado&#44; tal facto pode justificar&#8208;se pela presen&#231;a de valores de TG inferiores a 400&#44; o que se reflete num baixo erro no c&#225;lculo do LDL&#8208;c pela f&#243;rmula de Friedewald<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">25</span></a>&#46;</p><p id="par0500" class="elsevierStylePara elsevierViewall">A redu&#231;&#227;o aguda do HDL&#8208;c foi id&#234;ntica &#224; obtida por outros autores e relaciona&#8208;se com a redu&#231;&#227;o de TG&#44; que por sua vez s&#227;o muito dependentes da refei&#231;&#227;o pr&#233;via ao tratamento&#46; A longo prazo verificamos que n&#227;o h&#225; altera&#231;&#245;es significativas no valor de HDL&#8208;c&#44; facto que demonstra a seletividade da LDL&#8208;af&#233;rese pela t&#233;cnica DALI&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclus&#227;o</span><p id="par0505" class="elsevierStylePara elsevierViewall">Estes resultados refletem a elevada efic&#225;cia e seletividade da t&#233;cnica DALI e s&#227;o compar&#225;veis com resultados obtidos nos estudos pr&#233;vios que usaram a mesma t&#233;cnica<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">20&#44;21</span></a>&#46;</p><p id="par0510" class="elsevierStylePara elsevierViewall">Em 308 sess&#245;es durante 49 meses de seguimento da t&#233;cnica DALI esta demonstrou ser segura&#44; efetiva e seletiva para o LDL&#8208;c com redu&#231;&#245;es agudas superiores a 60&#37;&#44; sem altera&#231;&#227;o significativa das outras lipoprote&#237;nas&#46; O principal objetivo na redu&#231;&#227;o do LDL&#8208;c &#233; a preven&#231;&#227;o do desenvolvimento e da progress&#227;o da doen&#231;a ateroscler&#243;tica&#46; A melhoria no perfil lip&#237;dico observada repercutiu&#8208;se na aus&#234;ncia de progress&#227;o da doen&#231;a ateroscler&#243;tica&#46; A elimina&#231;&#227;o seletiva do LDL&#8208;c pela LDL&#8208;af&#233;rese representa uma evolu&#231;&#227;o decisiva no tratamento de doentes hipercolesterol&#233;micos com elevado risco cardiovascular<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0515" class="elsevierStylePara elsevierViewall">A LDL&#8208;af&#233;rese aliada &#224; terap&#234;utica farmacol&#243;gica hipolipemiante permitiu impedir a evolu&#231;&#227;o da doen&#231;a ateroscler&#243;tica em doentes com dislipidemia grave e risco cardiovascular muito elevado&#46;</p><p id="par0520" class="elsevierStylePara elsevierViewall">A baixa incid&#234;ncia de efeitos colaterais torna a LDL&#8208;af&#233;rese uma t&#233;cnica bem tolerada pelos doentes&#44; o que &#233; traduzido na elevada taxa de ades&#227;o ao tratamento&#46;</p><p id="par0525" class="elsevierStylePara elsevierViewall">A LDL&#8208;af&#233;rese pela t&#233;cnica DALI demonstrou ser um procedimento simples&#44; seguro e eficaz em doentes com HF resistentes ao tratamento nutricional e farmacol&#243;gico institu&#237;do&#46;</p><p id="par0530" class="elsevierStylePara elsevierViewall">A LDL&#8208;af&#233;rese deve ser ponderada como tratamento complementar da hipercolesterolemia em doentes intolerantes ou resistentes &#224;s estatinas ou doentes que apresentam contraindica&#231;&#245;es para a terap&#234;utica farmacol&#243;gica</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Responsabilidades &#233;ticas</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Prote&#231;&#227;o de pessoas e animais</span><p id="par0535" class="elsevierStylePara elsevierViewall">Os autores declaram que para esta investiga&#231;&#227;o n&#227;o se realizaram experi&#234;ncias em seres humanos e&#47;ou animais&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Confidencialidade dos dados</span><p id="par0540" class="elsevierStylePara elsevierViewall">Os autores declaram ter seguido os protocolos do seu centro de trabalho acerca da publica&#231;&#227;o dos dados de pacientes&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Direito &#224; privacidade e consentimento escrito</span><p id="par0545" class="elsevierStylePara elsevierViewall">Os autores declaram ter recebido consentimento escrito dos pacientes e&#47; ou sujeitos mencionados no artigo&#46; O autor para correspond&#234;ncia deve estar na posse deste documento&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflito de interesses</span><p id="par0550" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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              "titulo" => "Adsor&#231;&#227;o direta de lipoprote&#237;nas"
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              "identificador" => "sec0025"
              "titulo" => "M&#233;todos laboratoriais"
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              "identificador" => "sec0040"
              "titulo" => "Pacientes envolvidos"
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            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Doente 1"
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            2 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Doente 2"
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              "titulo" => "Doente 3"
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          "titulo" => "Discuss&#227;o"
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          "titulo" => "Responsabilidades &#233;ticas"
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              "titulo" => "Prote&#231;&#227;o de pessoas e animais"
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              "identificador" => "sec0080"
              "titulo" => "Confidencialidade dos dados"
            ]
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              "titulo" => "Direito &#224; privacidade e consentimento escrito"
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          "identificador" => "sec0090"
          "titulo" => "Conflito de interesses"
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          "titulo" => "Agradecimentos"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-05-29"
    "fechaAceptado" => "2014-07-31"
    "PalabrasClave" => array:2 [
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras&#8208;chave"
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          "palabras" => array:5 [
            0 => "Adsor&#231;&#227;o direta de lipoprote&#237;nas&#8208;af&#233;rese"
            1 => "Lipoprote&#237;nas de baixa densidade&#8208;af&#233;rese"
            2 => "Doen&#231;a cardiovascular"
            3 => "Lipoprote&#237;na &#40;a&#41;"
            4 => "Hipercolesterolemia familiar"
          ]
        ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:5 [
            0 => "Direct adsorption of lipoprotein apheresis"
            1 => "Low&#8208;density lipoprotein apheresis"
            2 => "Cardiovascular disease"
            3 => "Serum lipoprotein&#40;a&#41;"
            4 => "Familial hypercholesterolemia"
          ]
        ]
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      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A hipercolesterolemia manifestada pelos n&#237;veis elevados de colesterol das lipoprote&#237;nas de baixa densidade constitui um fator de risco <span class="elsevierStyleItalic">major</span> para o desenvolvimento e progress&#227;o da doen&#231;a ateroscler&#243;tica prematura&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A adsor&#231;&#227;o direta de lipoprote&#237;nas &#233; uma t&#233;cnica de LDL&#8208;af&#233;rese na qual o LDL&#8208;c pode ser seletivamente removido do sangue total&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Este trabalho partilha a experi&#234;ncia da LDL&#8208;af&#233;rese pela t&#233;cnica de adsor&#231;&#227;o direta de lipoprote&#237;nas no tratamento de doentes com hipercolesterolemia severa&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Tr&#234;s doentes com hipercolesterolemia e doen&#231;a ateroscler&#243;tica documentada foram tratados quinzenalmente com LDL&#8208;af&#233;rese pela t&#233;cnica de adsor&#231;&#227;o direta de lipoprote&#237;nas&#44; realizando no total 308 sess&#245;es entre dezembro de 2008 e janeiro de 2013&#46; Todos os doentes estavam medicados com estatinas e outros f&#225;rmacos hipolipemiantes na dose m&#225;xima tolerada&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">As sess&#245;es decorreram na generalidade sem intercorr&#234;ncias&#46; A incid&#234;ncia global de efeitos adversos reportados durante as sess&#245;es foi de 3&#44;6&#37;&#46; Em rela&#231;&#227;o aos par&#226;metros lip&#237;dicos obtivemos redu&#231;&#245;es agudas do colesterol das lipoprote&#237;nas de baixa densidade da ordem dos 63&#44;3&#37; &#40;m&#237;nimo de 57&#44;3&#37; e m&#225;ximo de 69&#44;6&#37;&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclus&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Em resumo&#44; a LDL&#8208;af&#233;rese pela t&#233;cnica de adsor&#231;&#227;o direta de lipoprote&#237;nas demonstrou ser um procedimento simples&#44; seguro e eficaz em doentes com hipercolesterolemia resistentes ao tratamento institu&#237;do&#46;</p></span>"
        "secciones" => array:5 [
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            "identificador" => "abst0005"
            "titulo" => "Introdu&#231;&#227;o"
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          1 => array:2 [
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "M&#233;todos"
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            "titulo" => "Resultados"
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            "titulo" => "Conclus&#227;o"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">High plasma levels of low&#8208;density lipoprotein &#40;LDL&#41; cholesterol are a risk factor for the development of premature atherosclerosis&#46;</p><p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Direct adsorption of lipoproteins &#40;DALI&#41; is an apheresis technique by which LDL cholesterol is selectively removed from whole blood&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objective</span><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">The present study describes our experience with DALI LDL apheresis in severely hypercholesterolemic patients&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Methods</span><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Three hypercholesterolemic patients suffering from atherosclerotic complications were treated fortnightly by DALI apheresis&#44; in a total of 308 sessions between December 2008 and January 2013&#46; All patients were on the highest tolerated dose of statins and other lipid&#8208;lowering drugs&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">The sessions were essentially uneventful&#44; adverse events being recorded in only 3&#46;6&#37; of them&#46; A mean 63&#46;3&#37; acute reduction in LDL cholesterol was obtained&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusion</span><p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">DALI apheresis proved to be a simple&#44; safe and efficient method of lipid apheresis in hypercholesterolemic patients refractory to conservative lipid&#8208;lowering therapy&#46;</p></span>"
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                "termino" => "CT"
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                "termino" => "DALI"
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                "termino" => "DM"
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                "termino" => "FDA"
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                "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">Fator de risco cardiovascular</p>"
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                "termino" => "HDL"
                "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">Lipoprote&#237;nas de alta densidade</p>"
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                "termino" => "HDL&#8208;c"
                "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">Colesterol das lipoprote&#237;nas de alta densidade</p>"
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              12 => array:2 [
                "termino" => "HAF"
                "descripcion" => "<p id="par0060" class="elsevierStylePara elsevierViewall">Hipercolesterolemia autoss&#243;mica recessiva</p>"
              ]
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                "termino" => "HF"
                "descripcion" => "<p id="par0065" class="elsevierStylePara elsevierViewall">Hipercolesterolemia familiar</p>"
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                "termino" => "HTA"
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                "termino" => "IDL"
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                "termino" => "IMC"
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                "termino" => "LDL&#8208;c"
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              ]
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                "termino" => "LDL&#8208;r"
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                "termino" => "Ldl&#8208;rap1"
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                "termino" => "VLDL"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pr&#233; &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8595; Ag&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pr&#233; &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8595; Ag&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pr&#233; &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8595; Ag&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">312&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">239&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">245&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">259&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">102&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">174&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">251&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">344&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">147&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">259&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">248&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">187&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">298&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">287&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">280&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">285&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">185&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">M&#233;dia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "pt" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Redu&#231;&#227;o aguda e redu&#231;&#227;o a longo prazo do LDL&#8208;c pela LDL&#8208;af&#233;rese pela t&#233;cnica de DALI</p>"
        ]
      ]
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        "etiqueta" => "Tabela 3"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Legenda&#58; &#8595; Ag&#58; redu&#231;&#227;o aguda do HDL&#8208;c&#59; HDL&#8208;c<span class="elsevierStyleInf">b</span>&#58; HDL&#8208;c basal&#59; HDL&#8208;c<span class="elsevierStyleInf">m</span>&#58; HDL&#8208;c m&#233;dio&#59; &#8595; Lp&#58; redu&#231;&#227;o a longo prazo do HDL&#8208;c&#46;</p><p id="spar0155" class="elsevierStyleSimplePara elsevierViewall">&#40;n&#8208;2&#41;&#44; &#40;n&#8208;1&#41; e &#40;n&#41; refere&#8208;se &#224;s tr&#234;s ultimas sess&#245;es&#44; respetivamente&#59; Pr&#233; e P&#243;s designa os valores antes e ap&#243;s o tratamento&#46;</p>"
          "tablatextoimagen" => array:1 [
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Doente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">HDL&#8208;c<span class="elsevierStyleInf">b</span>&#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sess&#227;o &#40;n&#8208;2&#41;</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sess&#227;o &#40;n&#8208;1&#41;</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sess&#227;o &#40;n&#41;</th><th class="td" title="table-head  " align="left" valign="top" scope="col">HDL&#8208;c<span class="elsevierStyleInf">m</span>&#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">&#8595; Lp &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pr&#233; &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8595; Ag&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pr&#233; &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8595; Ag&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pr&#233; &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8595; Ag&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">112&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">132&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">118&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">118&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">103&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;3&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;8&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;5&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">M&#233;dia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;2&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab709890.png"
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        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Redu&#231;&#227;o aguda e redu&#231;&#227;o a longo prazo de HDL&#8208;c pela LDL&#8208;af&#233;rese pela t&#233;cnica de DALI</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Tabela 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Legenda&#58; &#8595; Ag&#58; redu&#231;&#227;o aguda dos TG&#59; &#8595; Lp&#58; redu&#231;&#227;o a longo prazo dos TG&#59; TG<span class="elsevierStyleInf">b</span>&#58; TG basais&#59; TG<span class="elsevierStyleInf">m</span>&#58; TG m&#233;dios&#46;</p><p id="spar0160" class="elsevierStyleSimplePara elsevierViewall">&#40;n&#8208;2&#41;&#44; &#40;n&#8208;1&#41; e &#40;n&#41; refere&#8208;se &#224;s tr&#234;s ultimas sess&#245;es&#44; respetivamente&#59; Pr&#233; e P&#243;s designa os valores antes e ap&#243;s o tratamento&#46;</p>"
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            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="table-head  " align="left" valign="top" scope="col">Doente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">TG<span class="elsevierStyleInf">b</span>&#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sess&#227;o &#40;n&#8208;2&#41;</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sess&#227;o &#40;n&#8208;1&#41;</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sess&#227;o &#40;n&#41;</th><th class="td" title="table-head  " align="left" valign="top" scope="col">TG<span class="elsevierStyleInf">m</span>&#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">&#8595; Lp &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pr&#233; &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8595; Ag&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pr&#233; &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pr&#233; &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8595; Ag&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">140&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">158&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">111&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">109&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">103&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;6&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">108&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">M&#233;dia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Redu&#231;&#227;o aguda e redu&#231;&#227;o a longo prazo dos TG pela LDL&#8208;af&#233;rese pela t&#233;cnica de DALI</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Tabela 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Legenda&#58; &#8595; Ag&#58; redu&#231;&#227;o aguda do CT&#59; CT<span class="elsevierStyleInf">b</span>&#58; CT basal&#59; CT<span class="elsevierStyleInf">m</span>&#58; CT m&#233;dio&#59; &#8595; Lp&#58; redu&#231;&#227;o a longo prazo do CT&#46;</p><p id="spar0165" class="elsevierStyleSimplePara elsevierViewall">&#40;n&#8208;2&#41;&#44; &#40;n&#8208;1&#41; e &#40;n&#41; refere&#8208;se &#224;s tr&#234;s ultimas sess&#245;es&#44; respetivamente&#59; Pr&#233; e P&#243;s designa os valores antes e ap&#243;s o tratamento&#46;</p>"
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                0 => """
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">&#8595; Lp &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pr&#233; &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">390&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">309&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">156&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">311&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">140&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">332&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">158&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">404&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">217&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">388&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">222&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">318&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">379&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">360&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">159&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">369&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">376&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">161&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">M&#233;dia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "pt" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Redu&#231;&#227;o aguda e redu&#231;&#227;o a longo prazo do CT pela LDL&#8208;af&#233;rese pela t&#233;cnica de DALI</p>"
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          "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Legenda&#58; &#8595; Ag&#58; redu&#231;&#227;o aguda do nHDL&#8208;c&#59; &#8595; Lp&#58; redu&#231;&#227;o a longo prazo do nHDL&#8208;c&#59; nHDL&#8208;c<span class="elsevierStyleInf">b</span>&#58; HDL&#8208;c basal&#59; nHDL&#8208;c<span class="elsevierStyleInf">m</span>&#58; nHDL&#8208;c<span class="elsevierStyleInf">m</span> m&#233;dio&#46;</p><p id="spar0170" class="elsevierStyleSimplePara elsevierViewall">&#40;n&#8208;2&#41;&#44; &#40;n&#8208;1&#41; e &#40;n&#41; refere&#8208;se &#224;s tr&#234;s ultimas sess&#245;es&#44; respetivamente&#59; Pr&#233; e P&#243;s designa os valores antes e ap&#243;s o tratamento&#46;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">nHDL&#8208;c<span class="elsevierStyleInf">b</span>&#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pr&#233; &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8595; Ag&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P&#243;s &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8595; Ag&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">108&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">260&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">186&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">266&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">376&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">169&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">272&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">119&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">203&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">312&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">301&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">294&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">196&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">M&#233;dia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Expert Panel on Detection&#44; Evaluation&#44; and treatment of High Blood Cholesterol in Adults&#58; Third report of the National Cholesterol Education Program &#40;NCEP&#41; Expert panel on detection&#44; evaluation&#44; and treatment of high blood cholesterol in adults &#40;Adult Treatment Panel III&#41; final report"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation&#46;"
                        "fecha" => "2002"
                        "volumen" => "106"
                        "paginaInicial" => "3143"
                        "paginaFinal" => "3421"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12485966"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The inheritance of essential familial hypercholesterolemia"
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                        0 => array:2 [
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                            0 => "A&#46;K&#46; Khachadurian"
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Med&#46;"
                        "fecha" => "1964"
                        "volumen" => "37"
                        "paginaInicial" => "402"
                        "paginaFinal" => "407"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14209286"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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