Case report
Diaphragmatic patch: A useful adjunct in surgical treatment of recurrent catamenial hemothorax
J. Nwiloh
Section of Cardiothoracic Surgery, Atlanta Medical Center, Atlanta, GA, United States
Read
11981
Timeswas read the article
2733
Total PDF
9248
Total HTML
Share statistics
array:25 [ "pii" => "S0873215911000705" "issn" => "08732159" "doi" => "10.1016/j.rppneu.2011.06.006" "estado" => "S300" "fechaPublicacion" => "2011-11-01" "aid" => "34" "copyright" => "Sociedade Portuguesa de Pneumologia" "copyrightAnyo" => "2011" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Pneumol. 2011;17:278-80" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 7543 "formatos" => array:3 [ "EPUB" => 264 "HTML" => 6116 "PDF" => 1163 ] ] "itemSiguiente" => array:19 [ "pii" => "S0873215911001176" "issn" => "08732159" "doi" => "10.1016/j.rppneu.2011.07.007" "estado" => "S300" "fechaPublicacion" => "2011-11-01" "aid" => "54" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "dis" "cita" => "Rev Port Pneumol. 2011;17:281-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5516 "formatos" => array:3 [ "EPUB" => 257 "HTML" => 4168 "PDF" => 1091 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Comment</span>" "titulo" => "Comment to the article: Diaphragmatic patch: A useful adjunct in surgical treatment of recurrent catamenial hemothorax" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "281" "paginaFinal" => "282" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Comentário ao artigo: Penso diafragmático: um auxiliar útil para o tratamento cirúrgico de hemotórax recorrente catamenial" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. Borro" "autores" => array:1 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "Borro" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215911001176?idApp=UINPBA00004E" "url" => "/08732159/0000001700000006/v2_201509041318/S0873215911001176/v2_201509041318/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0873215911000651" "issn" => "08732159" "doi" => "10.1016/j.rppneu.2011.06.001" "estado" => "S300" "fechaPublicacion" => "2011-11-01" "aid" => "29" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Pneumol. 2011;17:275-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 8322 "formatos" => array:3 [ "EPUB" => 270 "HTML" => 6943 "PDF" => 1109 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "A massive pleural-based tumour: The challenge of diagnosis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "275" "paginaFinal" => "277" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 628 "Ancho" => 900 "Tamanyo" => 89320 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A large mass in the right hemi-thorax with low density suggestive of a lipoma/liposarcoma.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "H. Elsayed, J. Gosney" "autores" => array:2 [ 0 => array:2 [ "nombre" => "H." "apellidos" => "Elsayed" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Gosney" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215911000651?idApp=UINPBA00004E" "url" => "/08732159/0000001700000006/v2_201509041318/S0873215911000651/v2_201509041318/en/main.assets" ] "asociados" => array:1 [ 0 => array:19 [ "pii" => "S0873215911001176" "issn" => "08732159" "doi" => "10.1016/j.rppneu.2011.07.007" "estado" => "S300" "fechaPublicacion" => "2011-11-01" "aid" => "54" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "dis" "cita" => "Rev Port Pneumol. 2011;17:281-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5516 "formatos" => array:3 [ "EPUB" => 257 "HTML" => 4168 "PDF" => 1091 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Comment</span>" "titulo" => "Comment to the article: Diaphragmatic patch: A useful adjunct in surgical treatment of recurrent catamenial hemothorax" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "281" "paginaFinal" => "282" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Comentário ao artigo: Penso diafragmático: um auxiliar útil para o tratamento cirúrgico de hemotórax recorrente catamenial" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. Borro" "autores" => array:1 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "Borro" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215911001176?idApp=UINPBA00004E" "url" => "/08732159/0000001700000006/v2_201509041318/S0873215911001176/v2_201509041318/en/main.assets" ] ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Diaphragmatic patch: A useful adjunct in surgical treatment of recurrent catamenial hemothorax" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "278" "paginaFinal" => "280" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "J. Nwiloh" "autores" => array:1 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "Nwiloh" "email" => array:1 [ 0 => "Jnwiloh@gtcvsurg.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Section of Cardiothoracic Surgery, Atlanta Medical Center, Atlanta, GA, United States" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 497 "Ancho" => 1500 "Tamanyo" => 110422 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Diaphragmatic fenestrations. (B) Goretex patch repair of fenestrations.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">First patient</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 35 year nulliparous African American female who had had her last menstrual period a week previously, presented with dyspnea, right chest pain, abdominal pain and distension with onset of menses. Past medical history were primary infertility, thoracentesis for right hemothorax, video assisted thoracoscopy (VATS) for recurrent hemothorax, diagnostic laparoscopy and left ureteric stent for hydronephrosis, all 5 years earlier. She had had thoracotomy, decortication for recurrent hemothorax 5 months after the VATS. The previous diagnostic laparoscopy had revealed dense pelvic adhesions involving the uterus, ovaries and colon with retroperitoneal fibrosis causing left ureteric stricture and hydronephrosis. The patient had declined a hysterectomy at the time and was therefore treated medically with Lupron (Leuprolide) for 6 months followed by oral contraceptives. Paracentesis was repeated twice over the following 3 years for recurrent ascites. Admission workup at presentation included a chest X-ray, chest and abdominal CT which showed eventration of the right diaphragm, loculated pleural effusion, ascites and right ovarian cyst. She then underwent a redo-thoracotomy which revealed dense pleural adhesions, multiloculated hemothorax, with old bloody fluid seen entering from the abdomen through multiple diaphragmatic fenestrations with the largest measuring 2.5<span class="elsevierStyleHsp" style=""></span>cm. These were closed individually with 3/0 prolene sutures, followed by a Gore dualmesh patch (Gore & Associates, Newark, Delaware, USA) covering of the diaphragm with 3/0 prolene, followed by talc pleurodesis. (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B) Biopsies, cytology and cultures were all negative. Postoperative course was uneventful and she has had no recurrence at 18 months.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Second patient</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 31 year old African American female presented with history of weakness, abdominal bloating, distension and dyspnea at rest which had progressively gotten worse with onset of her menses 2 days earlier. She admitted to similar symptoms with each menstruation over the last 6 months. She also had history of dyspareunia and secondary infertility with inability to conceive after her first childbirth 11 years earlier. Past surgical history was significant for Appendectomy and Myomectomy 4 years earlier. Abdominal and pelvic ultrasound showed large pelvic and abdominal ascites. Chest X-ray and Chest CT scan showed opacification of the right hemothorax for which patient had initial thoracentesis with drainage of over 2<span class="elsevierStyleHsp" style=""></span>l of bloody effusion. Following reaccumulation of the hemothorax within a week, patient then underwent a right VATS pleural, diaphragmatic biopsies, goretex diaphragmatic patch and talc pleurodesis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The diaphragm looked erythematous and inflamed with dark brown reddish nodules. The biopsies were however all negative for endometriosis. Her post operative course was uneventful and patient has had no recurrence of hemothorax at 12 months follow up.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Endometriosis is estimated to affect 10-15% of women in their reproductive years.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Extrapelvic manifestation as thoracic endometriosis syndrome (TES) is relatively rare and in the largest series to date, Joseph and associates<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> in a retrospective review of all published cases in the English literature comprising 110 patients, revealed that 73% of the patients had pneumothorax, 14% hemothorax, 7% hemoptysis and 6% lung nodules. Similarly in a review of 43 patients with TES by Hibbard et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> pneumothorax was the most frequent presentation in 58%, followed by Hemothorax 19%, Hemoptysis 16% and 7% asymptomatic. The etiology of TES is multifactorial with three proposed theories: lymphatic or hematogenous embolization from the uterus; coelomic metaplasia and retrograde menstruation with transdiaphragmatic migration via congenital or acquired diaphragmatic defects. The diaphragmatic fenestrations seen in the first patient were probably acquired from hormonal induced cyclical necrosis of diaphragmatic endometrial implants as proposed by Alifano et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In the second patient although there were no visible fenestrations/holes seen at surgery, the rapid reaccumulation of right hemothorax after the initial drainage by thoracentesis and the subsequent failure to reaccumulate after the diaphragmatic patch support the possibility of occult diaphragmatic holes as the likely etiology in this patient as well. Histological evidence for TES is infrequent with only 37% and 52% of patients in the series by Hibbard et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and Korom et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> respectively had positive histology. Treatment of TES is controversial, with advocates for both medical and surgical treatments depending on individual circumstances and desire for children. Hormonal therapy is used to suppress the cyclical activities of endometrial implants with amelioration of symptoms, although often associated with high recurrence on discontinuation of the drug. For instance, Joseph and Sahn<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> report a 62% recurrence rate for hormonal therapy compared to 25% for surgical pleurodesis at one year with catamenial pneumothorax (CPTX) and in patients with catamenial hemothorax (CHT), 60% initially treated with hormone therapy also required surgery for recurrence.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Because definitive surgical treatment to remove the primary endometrial source by hysterectomy and bilateral salpingo-oophorectomy is often resisted by patients, who are usually young and still hoping to have children, surgical intervention is therefore usually directed at the local site of manifestation in the chest. Standard surgical treatment with pleurodesis alone for CPTX and CHT while superior to hormonal therapy still carries a significant incidence of recurrence especially with CHT where there is a higher incidence of diaphragmatic holes. To address this problem, Bagan et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> had reported 3 patients with recurrent CPTX and diaphragmatic defects repaired with polygalactin mesh with no recurrence at 35 months. They suggested that the mesh would cover any residual occult defects and also induce fibrotic adhesions to the lung. Since diaphragmatic fenestrations are more prevalent in CHT than CPTX cases with 71% versus 26% rates respectively in the series by Joseph and Sahn,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> it is logical to expect that they would be even more effective in reducing recurrence with CHT. Both our two patients treated with diaphragmatic patch covering have had no further recurrence at 18 and 12 months respectively following surgery. We therefore also would recommend a consideration of the adjunctive use of diaphragmatic patch with talc pleurodesis in recurrent CHT in patients found to have multiple fenestrations at surgery and those with bloody ascites even if there are no visible diaphragmatic pores as a means of reducing risk of further recurrence.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres547610" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec565491" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres547611" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec565490" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "First patient" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Second patient" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-02-14" "fechaAceptado" => "2011-05-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec565491" "palabras" => array:2 [ 0 => "Catamenial hemothorax" 1 => "Diaphragmatic pores" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec565490" "palabras" => array:2 [ 0 => "Hemotórax catamenial" 1 => "Poros diafragmáticos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Although catamenial hemothorax compared to pneumothorax is a rarer clinical presentation of thoracic endometriosis syndrome (TES), it is more commonly associated with diaphragmatic fenestrations. These openings may serve as entry portals for peritoneal fluid to access into the pleural space thereby perpetuating recurrent pleural effusion even after prior surgical pleurodesis. We report our experience with two patients with recurrent right catamenial hemothorax after previous interventions that were subsequently treated by talc pleurodesis and goretex diaphragmatic patch, and who have had no further recurrence at a mean follow up of 15 months.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We therefore recommend that diaphragmatic patch should be considered as an adjunct to talc pleurodesis in patients with recurrent catamenial hemothorax when either multiple diaphragmatic fenestrations are seen at surgery or if there is concomitant bloody peritoneal fluid which could potentially lead to recurrence. The patch by sealing any occult pores and possible future fenestrations appear to decrease recurrent pleural effusion at an intermediate term follow up.</p></span>" ] "es" => array:2 [ "titulo" => "Resumo" "resumen" => "<span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Embora o hemotórax catamenial comparado com o pneumotórax seja uma apresentação clínica mais rara de síndrome de endometriose torácica (TES), está mais associado a fenestrações diafragmáticas. Estas aberturas podem atuar como portais de entrada para o acesso ao fluido peritoneal na cavidade pleural, perpetuando assim o derrame pleural recorrente mesmo após uma pleurodese cirúrgica prévia. Registamos a nossa experiência em dois pacientes com hemotórax catamenial recorrente do lado direito após outras intervenções, que foram posteriormente tratados com pleurodese com talco e penso diafragmático em gore-tex, e que não apresentaram nenhuma outra recorrência durante um acompanhamento de 15 meses.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Recomendamos, então, que o penso diafragmático seja considerado um auxiliar à pleurodese com talco em pacientes com hemotórax catamenial recorrente, tanto quando são vistas várias fenestrações diafragmáticas na cirurgia, como quando há fluido peritoneal hemorrágico concomitante, que poderá conduzir a uma recorrência. O penso, ao selar qualquer poro oculto e possíveis fenestrações futuras, parece diminuir o derrame pleural recorrente num seguimento a médio prazo.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 497 "Ancho" => 1500 "Tamanyo" => 110422 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Diaphragmatic fenestrations. (B) Goretex patch repair of fenestrations.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 418 "Ancho" => 1500 "Tamanyo" => 97926 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">(A) Diaphragmatic surface. (B) Goretex patch of diaphragm.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thoracic endometriosis syndrome: new observations from analysis of 110 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Joseph" 1 => "S. Sahn" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Med" "fecha" => "1996" "volumen" => "100" "paginaInicial" => "164" "paginaFinal" => "170" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8629650" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thoracic endometriosis: a review and report of two cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Hibbard" 1 => "W. Schumann" 2 => "G. Goldstein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Obstet Gynecol" "fecha" => "1981" "volumen" => "140" "paginaInicial" => "227" "paginaFinal" => "232" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7234919" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thoracic endometriosis: current knowledge" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Alifano" 1 => "R. Trisolini" 2 => "A. Cancellieri" 3 => "J.F. Regnard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2005.07.044" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2006" "volumen" => "81" "paginaInicial" => "761" "paginaFinal" => "769" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16427904" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Catamenial pneumothorax revisited: clinical approach and systematic review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Korom" 1 => "H. Canyurt" 2 => "A. Missbach" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jtcvs.2004.04.039" "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2004" "volumen" => "128" "paginaInicial" => "502" "paginaFinal" => "508" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15457149" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Catamenial pneumothorax: retrospective study of surgical treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "P. Bagan" 1 => "F.L. Barthes" 2 => "J. Assouad" 3 => "R. Souilamas" 4 => "M. Riquet" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2003" "volumen" => "75" "paginaInicial" => "378" "paginaFinal" => "381" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12607643" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08732159/0000001700000006/v2_201509041318/S0873215911000705/v2_201509041318/en/main.assets" "Apartado" => array:4 [ "identificador" => "9580" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Casos clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/08732159/0000001700000006/v2_201509041318/S0873215911000705/v2_201509041318/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215911000705?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 9 | 19 |
| 2024 October | 52 | 27 | 79 |
| 2024 September | 67 | 25 | 92 |
| 2024 August | 79 | 32 | 111 |
| 2024 July | 46 | 33 | 79 |
| 2024 June | 71 | 61 | 132 |
| 2024 May | 70 | 35 | 105 |
| 2024 April | 49 | 29 | 78 |
| 2024 March | 43 | 32 | 75 |
| 2024 February | 42 | 19 | 61 |
| 2024 January | 44 | 24 | 68 |
| 2023 December | 33 | 28 | 61 |
| 2023 November | 38 | 34 | 72 |
| 2023 October | 34 | 28 | 62 |
| 2023 September | 34 | 28 | 62 |
| 2023 August | 38 | 22 | 60 |
| 2023 July | 32 | 22 | 54 |
| 2023 June | 36 | 17 | 53 |
| 2023 May | 48 | 32 | 80 |
| 2023 April | 63 | 23 | 86 |
| 2023 March | 56 | 20 | 76 |
| 2023 February | 29 | 25 | 54 |
| 2023 January | 42 | 17 | 59 |
| 2022 December | 52 | 22 | 74 |
| 2022 November | 65 | 38 | 103 |
| 2022 October | 64 | 31 | 95 |
| 2022 September | 44 | 38 | 82 |
| 2022 August | 51 | 43 | 94 |
| 2022 July | 55 | 44 | 99 |
| 2022 June | 45 | 32 | 77 |
| 2022 May | 53 | 37 | 90 |
| 2022 April | 47 | 25 | 72 |
| 2022 March | 47 | 38 | 85 |
| 2022 February | 42 | 36 | 78 |
| 2022 January | 45 | 32 | 77 |
| 2021 December | 43 | 40 | 83 |
| 2021 November | 31 | 29 | 60 |
| 2021 October | 30 | 39 | 69 |
| 2021 September | 26 | 26 | 52 |
| 2021 August | 39 | 26 | 65 |
| 2021 July | 41 | 21 | 62 |
| 2021 June | 27 | 18 | 45 |
| 2021 May | 43 | 30 | 73 |
| 2021 April | 65 | 60 | 125 |
| 2021 March | 125 | 14 | 139 |
| 2021 February | 88 | 23 | 111 |
| 2021 January | 39 | 8 | 47 |
| 2020 December | 47 | 10 | 57 |
| 2020 November | 42 | 25 | 67 |
| 2020 October | 61 | 16 | 77 |
| 2020 September | 85 | 25 | 110 |
| 2020 August | 86 | 23 | 109 |
| 2020 July | 125 | 29 | 154 |
| 2020 June | 119 | 15 | 134 |
| 2020 May | 91 | 16 | 107 |
| 2020 April | 98 | 17 | 115 |
| 2020 March | 69 | 16 | 85 |
| 2020 February | 117 | 16 | 133 |
| 2020 January | 93 | 25 | 118 |
| 2019 December | 93 | 18 | 111 |
| 2019 November | 98 | 16 | 114 |
| 2019 October | 92 | 17 | 109 |
| 2019 September | 87 | 15 | 102 |
| 2019 August | 140 | 22 | 162 |
| 2019 July | 137 | 14 | 151 |
| 2019 June | 152 | 10 | 162 |
| 2019 May | 183 | 20 | 203 |
| 2019 April | 135 | 27 | 162 |
| 2019 March | 168 | 11 | 179 |
| 2019 February | 130 | 7 | 137 |
| 2019 January | 183 | 20 | 203 |
| 2018 December | 107 | 6 | 113 |
| 2018 November | 42 | 2 | 44 |
| 2018 October | 59 | 13 | 72 |
| 2018 September | 30 | 8 | 38 |
| 2018 August | 40 | 28 | 68 |
| 2018 July | 45 | 25 | 70 |
| 2018 June | 62 | 12 | 74 |
| 2018 May | 39 | 25 | 64 |
| 2018 April | 116 | 34 | 150 |
| 2018 March | 72 | 14 | 86 |
| 2018 February | 33 | 15 | 48 |
| 2018 January | 51 | 13 | 64 |
| 2017 December | 67 | 12 | 79 |
| 2017 November | 53 | 20 | 73 |
| 2017 October | 37 | 11 | 48 |
| 2017 September | 40 | 15 | 55 |
| 2017 August | 28 | 18 | 46 |
| 2017 July | 28 | 16 | 44 |
| 2017 June | 44 | 22 | 66 |
| 2017 May | 42 | 19 | 61 |
| 2017 April | 24 | 7 | 31 |
| 2017 March | 20 | 7 | 27 |
| 2017 February | 82 | 6 | 88 |
| 2017 January | 21 | 4 | 25 |
| 2016 December | 27 | 23 | 50 |
| 2016 November | 38 | 14 | 52 |
| 2016 October | 47 | 13 | 60 |
| 2016 September | 61 | 9 | 70 |
| 2016 August | 49 | 8 | 57 |
| 2016 July | 9 | 11 | 20 |
| 2016 June | 0 | 7 | 7 |
| 2016 May | 5 | 0 | 5 |
| 2016 April | 33 | 3 | 36 |
| 2016 March | 69 | 10 | 79 |
| 2016 February | 67 | 10 | 77 |
| 2016 January | 74 | 12 | 86 |
| 2015 December | 63 | 7 | 70 |
| 2015 November | 60 | 14 | 74 |
| 2015 October | 55 | 6 | 61 |
| 2015 September | 55 | 9 | 64 |
| 2015 August | 56 | 7 | 63 |
| 2015 July | 50 | 12 | 62 |
| 2015 June | 35 | 8 | 43 |
| 2015 May | 70 | 11 | 81 |
| 2015 April | 59 | 9 | 68 |
| 2015 March | 71 | 7 | 78 |
| 2015 February | 73 | 7 | 80 |
| 2015 January | 58 | 12 | 70 |
| 2014 December | 60 | 18 | 78 |
| 2014 November | 76 | 5 | 81 |
| 2014 October | 55 | 8 | 63 |
| 2014 September | 56 | 9 | 65 |
| 2014 August | 79 | 8 | 87 |
| 2014 July | 67 | 8 | 75 |
| 2014 June | 58 | 7 | 65 |
| 2014 May | 71 | 7 | 78 |
| 2014 April | 62 | 11 | 73 |
| 2014 March | 73 | 8 | 81 |
| 2014 February | 66 | 12 | 78 |
| 2014 January | 64 | 7 | 71 |
| 2013 December | 63 | 6 | 69 |
| 2013 November | 64 | 9 | 73 |
| 2013 October | 68 | 11 | 79 |
| 2013 September | 48 | 12 | 60 |
| 2013 August | 58 | 19 | 77 |
| 2013 July | 77 | 20 | 97 |
| 2013 June | 57 | 14 | 71 |
| 2013 May | 85 | 23 | 108 |
| 2013 April | 87 | 31 | 118 |
| 2013 March | 76 | 11 | 87 |
| 2013 February | 58 | 18 | 76 |
| 2013 January | 60 | 17 | 77 |
| 2012 December | 45 | 15 | 60 |
| 2012 November | 46 | 21 | 67 |
| 2012 October | 24 | 9 | 33 |
| 2012 September | 18 | 6 | 24 |
| 2012 January | 267 | 0 | 267 |
Show all
