Letter to the Editor
Poland syndrome and pneumothorax: the compelling evidence of an association
Margarida Afonsoa,
, Tiago Alfaroa,b, Jessica Cemlyn-Jonesa,b, Carlos Robalo Cordeiroa,b
Corresponding author
margaridaiafonso@gmail.com
Corresponding author. Margarida Afonso; Pneumology Unit A, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal; Tel.: +30 400 400.
Corresponding author. Margarida Afonso; Pneumology Unit A, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal; Tel.: +30 400 400.
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Pulmonary infiltrates patched with airborne bronchogram (thick arrow) and areas of tarnished glass predominantly right lower lobe (arrowhead).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Figure 1B: Coronal cut computerized tomography. A small abscess is shown in the diaphragmatic region (thick arrow) and calcified hydatid cyst (arrowhead).</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Figure 1C: Axial cut computerized tomography. Abscess (thick arrow) between the posterior hepatic rim and the lower right lobe, with a small air bubble inside.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Figure 1D: Coronal cut of hepatic magnetic resonance imaging in hepato-specific phase with bile duct contrast excretion at the same level as Figure 1B. Abscess (thick arrow) and fistulous path (thin arrow) are shown.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Figure 1E: Axial cut of hepatic magnetic resonance imaging in hepato-specific phase with bile duct contrast excretion at the same level as Figure 1C. Fistulous tract (thin arrow) and abscess (thick arrow) leading to the anterobasal segment of the lower right lobe.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Romina Abelleira, María Elena Toubes, Anxo Martínez de Alegría, Luis Valdés" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Romina" "apellidos" => "Abelleira" ] 1 => array:2 [ "nombre" => "María Elena" "apellidos" => "Toubes" ] 2 => array:2 [ "nombre" => "Anxo Martínez de" "apellidos" => "Alegría" ] 3 => array:2 [ "nombre" => "Luis" "apellidos" => "Valdés" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043718301156?idApp=UINPBA00004E" "url" => "/25310437/0000002400000005/v1_201810040621/S2531043718301156/v1_201810040621/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2531043718301089" "issn" => "25310437" "doi" => "10.1016/j.pulmoe.2018.06.007" "estado" => "S300" "fechaPublicacion" => "2018-09-01" "aid" => "51" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Pulmonol. 2018;24:314-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1384 "formatos" => array:3 [ "EPUB" => 160 "HTML" => 804 "PDF" => 420 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the editor</span>" "titulo" => "Fat embolism syndrome presenting as diffuse alveolar hemorrhage: a rare (known) association" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "314" "paginaFinal" => "315" ] ] "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" => 988 "Ancho" => 1500 "Tamanyo" => 176295 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest CT axial image showing areas of “crazy-paving” pattern representing diffuse alveolar hemorrhage.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Seixas, P.G. Ferreira" "autores" => array:2 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Seixas" ] 1 => array:2 [ "nombre" => "P.G." "apellidos" => "Ferreira" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043718301089?idApp=UINPBA00004E" "url" => "/25310437/0000002400000005/v1_201810040621/S2531043718301089/v1_201810040621/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Poland syndrome and pneumothorax: the compelling evidence of an association" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">Dear Editor:</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "316" "paginaFinal" => "317" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Margarida Afonso, Tiago Alfaro, Jessica Cemlyn-Jones, Carlos Robalo Cordeiro" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Margarida" "apellidos" => "Afonso" "email" => array:1 [ 0 => "margaridaiafonso@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Tiago" "apellidos" => "Alfaro" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Jessica" "apellidos" => "Cemlyn-Jones" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Carlos Robalo" "apellidos" => "Cordeiro" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Pneumology Unit A, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centre of Pneumology, Faculty of Medicine of the University of Coimbra, Coimbra, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author. Margarida Afonso; Pneumology Unit A, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal; Tel.: +30 400 400." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 820 "Ancho" => 1508 "Tamanyo" => 119529 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Thorax CT – showing left pectoralis muscle atrophy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Poland Syndrome is a rare congenital deformity which mainly occurs sporadically but occasional familial cases have been reported.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is characterized by unilateral absence of pectoralis muscle, typically in association with other deformities of the ipsilateral chest wall and/or upper limbs.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> According to recent classifications, the pectoralis muscle anomaly alone is enough to establish diagnosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It predominantly affects the right hemithorax (67-75%), with rare bilateral cases described.<span class="elsevierStyleSup">(1)</span> The most commonly accepted causal mechanism is related to disruption of blood supply through the subclavian artery during embryogenesis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Incidence varies from 1/70000 to 1/100000 live births, with a male to female ratio of 2-3 to 1.<span class="elsevierStyleSup">(1)</span> Due to mild or even non-existent functional impairment, the condition is thought to be under-reported and underdiagnosed. Surgical correction is recommended in cases of significant functional or aesthetic impairment.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 19 year-old male, admitted to the emergency room presenting with left-sided chest pain 24<span class="elsevierStyleHsp" style=""></span>hours after onset. He had no other complaints and there was no precipitating event, <span class="elsevierStyleBold">such</span> as, trauma or infection.The patient was a non-smoker; with no relevant personal or family past medical history.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination showed the patient to be tachycardic and slightly polypneic. Thoracic inspection showed hypoplasia of the left thoracic wall due to the underdevelopment of the left pectoralis muscle and decreased chest expansion. No other structural abnormalities were observed on the affected side of the torso.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Also on the left hemithorax, there was hyperresonance to percussion and absent breath sounds on ausculation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Chest x-ray showed a large left lung pneumothorax; a chest tube was successfully placed with clinical improvement and total lung expansion. Thoracic computer tomography (<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>) revealed hypoplasia of the major pectoralis muscle confirming the diagnosis of Poland Syndrome and ruled out other abnormalities. There was full resolution of the pneumothorax and the chest tube was removed after four days.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The definition of Poland Syndrome includes variable musculoskeletal deformities in multiple musculoskeletal structures, typically ipsilateral to the pectoralis major muscle hypoplasia.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> As it is a rare, heterogeneous condition, the documentation of clinical cases and case series is of particular relevance for better understanding of its causes and physiopathology.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The case here presented of Poland syndrome and pneumothorax reinforces the hypothesis of an association between the two clinical entities. We carried out a systematic review on Pubmed and Embase databases; the results are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. We identified five cases, all male patients, aged between 16 and 27 years. As well as the case described, there was one other which presented with a left-sided deformity, and three isolated pectoralis major muscle anomalies. Only in one case was the pneumothorax contralateral to the muscle hypoplasia; in four patients parenchymal bullae were found. The prevailing theory about the pathophysiology of this association refers to changes in the blood supply through the brachial arch during embryogenesis.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5</span></a> Disruption at this level potentially affects the development of the lungs and pleura, increasing the risk of spontaneous primary pneumothorax. Cigarette smoking as an additional risk factor for pneumothorax should be considered, although no information about smoking habits has been included in previous case reports. Management approaches for primary spontaneous pneumothorax vary widely between institutions. The recommendations of the British Thoracic Society favour a conservative approach preferring aspiration to thoracostomy,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> however it is recognized that this approach is often ineffective and many medical institutions do not follow these recommendations.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In the case described, a 24F chest tube was chosen based on availability and experience in our emergency services. The first episodes of cases 1 and 2,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> as well as case 3,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> were also managed by thoracostomy. The recurrent nature of cases 1 and 2<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and the existence of bullous parenchymal changes in cases 4 and 5<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> led to a decision for surgical treatment. We can also draw attention to the fact that there are no specific recommendations for the treatment of pneumothorax in a patient with Poland Syndrome. There was a positive clinical outcome in all the cases reported, including this one.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">This case supports the theory that the morphological alterations observed in Poland syndrome can extend to the pleural and pulmonary parenchyma and that therefore this population may benefit from greater clinical surveillance.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The possible hypothesized association between these two clinical entities is dependent on the reporting and analysis of more cases. Also, longitudinal epidemiological studies may be useful.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Disclosure</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors report no financial support, off-label or investigational drug use.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Disclosure" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 797 "Ancho" => 1508 "Tamanyo" => 99016 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Thorax CT – showing left pectoralis muscle atrophy.</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" => 820 "Ancho" => 1508 "Tamanyo" => 119529 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Thorax CT – showing left pectoralis muscle atrophy.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">+</span> Location of pectoralis muscle deformity; <span class="elsevierStyleBold">*</span> Additional musculoskeletal deformities; <span class="elsevierStyleSup">&</span> Location in relation to the pectoralis muscle deformity; <span class="elsevierStyleSup"><span class="elsevierStyleBold">$</span></span> Shortening of fingers; <span class="elsevierStyleSup"><span class="elsevierStyleBold">#</span></span> Limb shortening;<span class="elsevierStyleBold">°</span> Recurrent pneumothorax.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case number \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">Age \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">Hemi thorax<span class="elsevierStyleSup">+</span> \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">Musculoskeletal anomalies <span class="elsevierStyleSup">*</span> \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">Pneumothorax<span class="elsevierStyleSup">&</span> \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">Apical bullous alterations \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">Ref. \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contralateral° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Brachydactyly<span class="elsevierStyleSup">$</span> of the ipsilateral hand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ipsilateral° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ipsilateral superior micromelia<span class="elsevierStyleSup">#</span> with shoulder and elbow joint mobility restriction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ipsilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ipsilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ipsilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1864268.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Main characteristics of previous described cases associating Poland syndrome and pneumothorax. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 17 | 8 | 25 |
| 2024 October | 80 | 30 | 110 |
| 2024 September | 112 | 29 | 141 |
| 2024 August | 130 | 33 | 163 |
| 2024 July | 105 | 33 | 138 |
| 2024 June | 76 | 38 | 114 |
| 2024 May | 72 | 40 | 112 |
| 2024 April | 70 | 33 | 103 |
| 2024 March | 59 | 17 | 76 |
| 2024 February | 43 | 25 | 68 |
| 2024 January | 48 | 31 | 79 |
| 2023 December | 47 | 23 | 70 |
| 2023 November | 69 | 36 | 105 |
| 2023 October | 43 | 35 | 78 |
| 2023 September | 44 | 36 | 80 |
| 2023 August | 36 | 11 | 47 |
| 2023 July | 43 | 32 | 75 |
| 2023 June | 27 | 12 | 39 |
| 2023 May | 56 | 30 | 86 |
| 2023 April | 32 | 19 | 51 |
| 2023 March | 70 | 33 | 103 |
| 2023 February | 40 | 33 | 73 |
| 2023 January | 37 | 20 | 57 |
| 2022 December | 63 | 17 | 80 |
| 2022 November | 69 | 45 | 114 |
| 2022 October | 92 | 36 | 128 |
| 2022 September | 41 | 28 | 69 |
| 2022 August | 37 | 33 | 70 |
| 2022 July | 35 | 64 | 99 |
| 2022 June | 44 | 79 | 123 |
| 2022 May | 48 | 47 | 95 |
| 2022 April | 41 | 35 | 76 |
| 2022 March | 70 | 53 | 123 |
| 2022 February | 77 | 28 | 105 |
| 2022 January | 101 | 41 | 142 |
| 2021 December | 38 | 48 | 86 |
| 2021 November | 41 | 28 | 69 |
| 2021 October | 57 | 42 | 99 |
| 2021 September | 46 | 42 | 88 |
| 2021 August | 45 | 30 | 75 |
| 2021 July | 47 | 17 | 64 |
| 2021 June | 34 | 20 | 54 |
| 2021 May | 60 | 42 | 102 |
| 2021 April | 111 | 78 | 189 |
| 2021 March | 74 | 43 | 117 |
| 2021 February | 46 | 23 | 69 |
| 2021 January | 47 | 29 | 76 |
| 2020 December | 27 | 16 | 43 |
| 2020 November | 36 | 21 | 57 |
| 2020 October | 49 | 39 | 88 |
| 2020 September | 43 | 34 | 77 |
| 2020 August | 49 | 27 | 76 |
| 2020 July | 47 | 27 | 74 |
| 2020 June | 47 | 33 | 80 |
| 2020 May | 52 | 30 | 82 |
| 2020 April | 42 | 15 | 57 |
| 2020 March | 48 | 24 | 72 |
| 2020 February | 27 | 17 | 44 |
| 2020 January | 37 | 34 | 71 |
| 2019 December | 42 | 23 | 65 |
| 2019 November | 34 | 20 | 54 |
| 2019 October | 37 | 24 | 61 |
| 2019 September | 48 | 21 | 69 |
| 2019 August | 70 | 28 | 98 |
| 2019 July | 71 | 25 | 96 |
| 2019 June | 72 | 18 | 90 |
| 2019 May | 86 | 33 | 119 |
| 2019 April | 62 | 42 | 104 |
| 2019 March | 54 | 22 | 76 |
| 2019 February | 49 | 32 | 81 |
| 2019 January | 63 | 46 | 109 |
| 2018 December | 30 | 8 | 38 |
| 2018 November | 2 | 0 | 2 |
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