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Mass carbon monoxide poisoning among television viewers of a football match
Brote masivo de intoxicación por monóxido de carbono en los telespectadores de un partido de fútbol
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"apellidos" => "Alsedà" "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:3 [ 0 => array:3 [ "entidad" => "Agencia de Salud Pública de Cataluña, Generalidad de Cataluña, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Institut de Recerca Biomèdica (IRB) de Lleida, Facultad de Medicina, Universidad de Lleida, Lleida, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "CIBER de Epidemiología y Salud Pública (CIBERESP), Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Brote masivo de intoxicación por monóxido de carbono en los telespectadores de un partido de fútbol" ] ] "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" => 794 "Ancho" => 1434 "Tamanyo" => 65252 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Epidemic curve for the onset of cases from a mass carbon monoxide poisoning by a butane stove.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Carbon monoxide (CO) poisoning is a common reason for emergency department visits.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1–3</span></a> CO is a colorless, odorless and nonirritating gas. Its affinity for hemoglobin is 200-fold greater than that of oxygen and therefore forms carboxyhemoglobin (COHb) even with minor exposure.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> Exposure to moderate quantities causes headaches, nausea, muscle weakness and dizziness, which can imitate the common cold and is often incorrectly diagnosed.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">4,5</span></a> More significant poisonings are potentially severe and can cause confusion, seizures, loss of consciousness and even death.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1,6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The measurement of COHb levels is indicated for the diagnosis, although its reliability decreases as the length of time since the exposure increases.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> The COHb levels depend on numerous factors, such as the magnitude of the exposure, alveolar ventilation, blood volume and metabolic activity. In adults at rest, these levels are mainly influenced by the level of CO in the environment and the duration of exposure.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> A COHb level greater than 3% in nonsmokers or greater than 10% in smokers confirms CO exposure.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> However, a number of studies have indicated that COHb levels do not correlate with the presence or absence of initial symptoms or with subsequent sequela, which can be attributed to inflammatory mechanisms triggered by the poisoning more than to the hypoxia itself.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> Detecting asymptomatic poisoned individuals is unusual given that people are generally only admitted to emergency departments if they have some type of symptom.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this study was to report a mass CO poisoning that affected a large group of television viewers of a football match and to compare the symptomatic confirmed cases with the asymptomatic ones.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">On February 2, 2015, the epidemiology unit of Lleida was notified that more than 30 individuals from a football group had contacted the emergency department of University Hospital Arnau de Vilanova of Lleida the previous night due to alleged CO poisoning from a butane stove in a social setting. An epidemiological study was designed to report the mass poisoning, the individuals affected and the factors associated with the poisoning and with the presence of clinical symptoms.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The local government and those responsible for the football group were contacted, and a comprehensive list of the individuals exposed was obtained. A visual inspection of the locale where the exposure took place was conducted, during which the presence of a butane stove for outside use was confirmed. An epidemiological survey of those exposed individuals was conducted, and their medical histories were reviewed. We collected information on epidemiological (time of exposure and distance from the stove), clinical (history of chronic diseases, toxic habits and symptoms), laboratory (COHb levels) and treatment (oxygen and hyperbaric chamber) variables. We used the definition of “confirmed case” of the Centers for Disease Control (Atlanta, US): nonsmoker patient with COHb levels >5% or smoker with levels >10%.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a> We also considered as probable cases those patients with compatible symptoms (2 or more of the following symptoms: headache, nausea, weakness, dizziness, disorientation, dyspnea, nervousness or seizures) but with no COHb reading or a reading performed more than 6<span class="elsevierStyleHsp" style=""></span>h after the exposure.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The attack rate was calculated, and an epidemic curve was prepared. We conducted a bivariate analysis to compare the patients who met the definition of case with the rest of the exposed patients. The cases confirmed by symptoms were also compared to the confirmed asymptomatic cases. The presence of a statistical association was studied with Fisher's exact test for qualitative variables or the Kruskal–Wallis nonparametric test when one of them was quantitative. Values of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05 were considered significant.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">Thirty-nine exposed individuals were studied. Their mean age was 43.8<span class="elsevierStyleHsp" style=""></span>years (SD, 22.1), and 11 (28.2%) of them were women. Nine (23.1%) individuals had a previous disease or chronic disorder such as arterial hypertension (6, 66.7%), diabetes (4, 44.4%) or ischemic heart disease (2, 22.2%). The mean exposure time was 52.4<span class="elsevierStyleHsp" style=""></span>min (SD, 21.0), and the mean distance from the stove was 4.2<span class="elsevierStyleHsp" style=""></span>m (SD, 2.5). Most cases (31) were confirmed by measuring COHb in blood. Only 3 of those exposed were considered probable cases due to presenting compatible symptoms but with no reliable COHb reading.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The attack rate was very high (34, 87.2%). The patients’ symptoms were headache (50%), nausea (20.6%), weakness (20.6%), dizziness (14.7%), disorientation (8.8%), dyspnea (8.8%), vomiting (2.9%), nervousness (2.9%), syncope (2.9%) and seizures (2.9%). The mean COHb level was 13.9% (SD, 5.8). Thirty-three patients required oxygen therapy (97.1%), and 13 (39.4%) were referred for hyperbaric chamber treatment.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The visual inspection of the locale where the exposure took place verified the presence of a butane gas stove, which, despite being intended exclusively for outside use, was used to rapidly heat a room of approximately 30<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> used by the football group of Vilanova de la Barca (Lleida) to watch football matches. The stove was lit at approximately 7:30<span class="elsevierStyleHsp" style=""></span>pm, and by 8:15<span class="elsevierStyleHsp" style=""></span>pm the first cases had occurred. The football match began at 8:30<span class="elsevierStyleHsp" style=""></span>pm, and, according to the epidemic curve, the largest number of cases showed up halfway through the match (between 9:15 and 9:30<span class="elsevierStyleHsp" style=""></span>pm) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Compared with the asymptomatic cases, the participants with symptoms had a higher mean age (48.0 vs. 16.5 years; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.003) and, logically, a higher COHb level (13.9% vs. 4.6%; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.005) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The risk of poisoning was not associated with the distance from the stove or with the exposure time, although the study lacked statistical power for explain this lack of association (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Ten patients (29.5%) with confirmed cases presented no symptoms (29.5%). The asymptomatic cases had COHb levels similar to those of the symptomatic cases (13.6% vs. 15.3%; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>.05) but a shorter exposure time (38.3 vs. 53.3<span class="elsevierStyleHsp" style=""></span>min; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.036) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">The study describes a mass CO poisoning with a very high attack rate due to the improper use of a butane stove in the interior of a social locale. The poisoning was potentially severe for those affected by it, and almost 40% of the patients required oxygen treatment in a hyperbaric chamber. We observed a high percentage of exposed individuals with COHb levels compatible with the definition of confirmed case but who were asymptomatic and still required treatment in a hyperbaric chamber.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The study has significant limitations. The attack rate was extremely high (87.2%) which suggests that the environmental CO levels were very high.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">4,7</span></a> This finding is compatible with very high COHb concentrations observed in the cases (mean, 13.9%), which were similar to those described in other published mass poisonings with severe cases.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> The youths had a lower risk of poisoning, which could be explained by, among other factors, a lower exposure due to increased movement and their entering and exiting the locale. It has been documented that the response to CO exposure varies with age.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">6,7</span></a> Although children and adolescents can present earlier symptoms, they recover more rapidly due to their lower volume of blood and to greater ventilation per body mass unit.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The incident sounded a major alarm among the affected group, which caused all of the exposed individuals to contact the emergency department. This action helped verify that a high percentage of asymptomatic individuals presented COHb levels compatible with the definition of a case (29.5%) and who also required oxygen therapy or hyperbaric chamber treatment. In fact, the asymptomatic cases had COHb levels similar to those of the symptomatic cases. The percentage of individuals with CO poisoning who remained asymptomatic in the published mass poisonings were, in general, not known because usually it is only those individuals with symptoms who go to healthcare services.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">8,9,11</span></a> This study suggests that this percentage could be significant. Consequently, all individuals exposed to high CO levels, in the context of mass exposure, should be evaluated and have their COHb levels measured to determine whether they could benefit from oxygen therapy or hyperbaric chamber treatment.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">4,12</span></a> The risk of sequela in poisoned individuals can be high, and various studies have indicated that hyperbaric oxygen could be of potential benefit to prevent sequela.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">7,12</span></a> Treatment with hyperbaric oxygen improves the arterial concentration and pressure of oxygen in the tissue, promotes the elimination of CO and reduces oxidative stress and inflammation.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> In fact, it is recommended that patients poisoned by CO undergo medical follow-up after being discharged. The recovery rate after poisoning varies and is often complicated by the onset of sequela that can persist after the exposure or develop weeks after the event.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">13–16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The butane stove that caused the poisoning had been previously used. Two days earlier, a member of the same group with prior renal failure presented symptoms of syncope while seated beside the stove. However, this episode was not related to a potential CO poisoning. This case could be revealing for potential episodes of previous inadvertent poisonings. In fact, poisonings can occur without resulting in symptoms, as demonstrated in the mass poisoning described above, or in mild symptoms that are not diagnosed as CO poisoning.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">8,9,11,17,18</span></a> Therefore, it is important that emergency departments, when faced with nonspecific conditions of headache, nausea, muscle weakness and dizziness, consider a possible CO poisoning as a cause of the symptoms, especially in winter.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1,11,17,18</span></a> Additionally, due to the financial crisis, the use of cheaper heating systems can result in greater exposure and risk of CO poisonings.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">8,9</span></a> Thus, it is important that both the public and practitioners have the necessary information to prevent and detect this problem.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">2,18,19</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Other measures that can help control these poisonings are the proper use of heating devices and domestic hot water heaters, avoiding the use of combustion engines inside houses, the periodic inspection of the devices to ensure correct operation and the availability of alarms to detect high CO levels in risk situations.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">7,11</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The study has a number of limitations. The patients’ COHb readings were performed when they contacted the emergency department. Most of the patients contacted the department 30<span class="elsevierStyleHsp" style=""></span>min to 3<span class="elsevierStyleHsp" style=""></span>h after the exposure, but a number of them did so the following day when more than 12<span class="elsevierStyleHsp" style=""></span>h had elapsed. Given that COHb levels decrease rapidly over time after the exposure, the levels detected would be lower than those to which the patients were truly exposed. Most of the patients arrived at the locale at the start of the football match, but some arrived before the stove was lit. The epidemic curve is therefore not a reliable reflection of the start of exposure for all those exposed. The exposure time and distance from the stove were difficult to determine, given that a number of the individuals changed position over the course of the match, and some, especially children, exited the locale a few times.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion, we report a mass CO poisoning in which a high percentage of individuals who were confirmed to be poisoned (according to COHb levels) were asymptomatic. Therefore, we recommend assessing COHb levels in all individuals exposed to mass CO poisonings, even if they have no symptoms. The public and health practitioners should be informed of the risk of CO poisoning, especially in winter when using heating systems that can generate CO.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres750223" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec752977" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres750222" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec752978" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-01-29" "fechaAceptado" => "2016-04-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec752977" "palabras" => array:5 [ 0 => "Poisoning" 1 => "Carbon monoxide" 2 => "Outbreak" 3 => "Epidemiology" 4 => "Asymptomatic" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec752978" "palabras" => array:5 [ 0 => "Intoxicación" 1 => "Monóxido de carbono" 2 => "Brote" 3 => "Epidemiología" 4 => "Asintomáticos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The objective was to study a mass carbon monoxide (CO) poisoning and the characteristics of the asymptomatic cases.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">On the 2nd of February, 2015, a group of more than 30 television viewers of a football match contacted the emergency department due to suspected CO poisoning from a butane stove. A visual inspection of the location of the exposure and a descriptive epidemiological study were conducted. Based on the type of variable, the presence of a statistical association was studied with Fisher's exact test or the Kruskal–Wallis test.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thirty-four of the 39 individuals were affected (87.2%). The exposed individuals had a mean age of 43.8 years (SD, 22.1), and 28.2% (11/39) were women. The time of exposure was 52.4<span class="elsevierStyleHsp" style=""></span>min (SD, 21.0), and the mean distance from the oven was 4.2<span class="elsevierStyleHsp" style=""></span>m (SD, 2.5). The most common symptoms were headache (50%), nausea (20.6%), weakness (20.6%) and dizziness (14.7%). The carboxyhaemoglobin (COHb) levels were very high (13.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.8%). Some 97.1% of the individuals required oxygen therapy, and 39.4% required hyperbaric chamber treatment. Some 29.5% of the cases had no symptoms but showed COHb levels similar to those that did have symptoms (13.6% vs. 15.3%, nonsignificant difference). The asymptomatic cases had a shorter exposure time (38.3<span class="elsevierStyleHsp" style=""></span>min vs. 53.3<span class="elsevierStyleHsp" style=""></span>min; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.036).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Almost a third of the exposed individuals were asymptomatic, even with COHb levels similar to those of the symptomatic patients, and the majority of these asymptomatic patients even required oxygen treatment in a hyperbaric chamber.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo fue estudiar un brote de intoxicación por monóxido de carbono (CO) y las características de los casos asintomáticos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El 2 de febrero de 2015 un grupo de más de 30 telespectadores de un partido de fútbol contactó con el servicio de urgencias por una supuesta intoxicación por CO procedente de una estufa de butano. Se realizó una inspección ocular del local de la exposición y un estudio epidemiológico descriptivo. Según el tipo de variables, la existencia de una asociación estadística se estudió con la prueba exacta de Fisher o el test de Kruskal–Wallis.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se vieron afectados 34 de 39 sujetos (87,2%). Los expuestos tenían una media de edad de 43,8<span class="elsevierStyleHsp" style=""></span>años (DE<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>22,1) y el 28,2% (11/39) eran mujeres. El tiempo de exposición fue de 52,4<span class="elsevierStyleHsp" style=""></span>min (DE<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21,0) y la distancia a la estufa de 4,2<span class="elsevierStyleHsp" style=""></span>m (DE<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2,5). Los síntomas más frecuentes fueron cefalea (50%), náuseas (20,6%), pérdida de fuerza (20,6%) y vértigo (14,7%). Los niveles de carboxihemoglobina (COHb) fueron muy elevados (13,8%<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5,8). El 97,1% precisó oxigenoterapia y el 39,4% tratamiento en cámara hiperbárica. Un 29,5% de los casos no presentaron síntomas, y respecto a los casos sintomáticos, estos mostraron niveles similares de COHb (13,6% vs. 15,3%, diferencia no significativa), pero un tiempo de exposición inferior (38,3<span class="elsevierStyleHsp" style=""></span>min vs. 53,3<span class="elsevierStyleHsp" style=""></span>min; p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,036).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Casi una tercera parte de las personas expuestas fueron asintomáticas aun con niveles de COHb similares a los casos sintomáticos, e incluso la mayoría precisaron tratamiento con oxígeno en cámara hiperbárica.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Godoy P, Pont C, Artigues A, Alsedà M. Brote masivo de intoxicación por monóxido de carbono en los telespectadores de un partido de fútbol. Rev Clin Esp. 2016;216:409–413.</p>" ] ] "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" => 794 "Ancho" => 1434 "Tamanyo" => 65252 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Epidemic curve for the onset of cases from a mass carbon monoxide poisoning by a butane stove.</p>" ] ] 1 => 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:3 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>: COHb, carboxyhemoglobin.</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">Variable \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">Case, <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>34 (%) \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">No case, <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5 (%) \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"><span class="elsevierStyleItalic">p</span> \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 " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Sex</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (29.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (20.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.05 \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"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (70.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (80.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age (years)</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.9 (19.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.6 (16.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Smoker</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (14.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (20.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.05 \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"><span class="elsevierStyleHsp" style=""></span>No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (85.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (80.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Chronic diseases</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (26.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.05 \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"><span class="elsevierStyleHsp" style=""></span>No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (73.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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"><span class="elsevierStyleItalic">COHb (%)</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.9 (5.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.6 (2.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.005 \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"><span class="elsevierStyleItalic">Distance from the stove</span>, <span class="elsevierStyleItalic">m</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.0 (2.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.4 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.05 \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"><span class="elsevierStyleItalic">Exposure time, min</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.3 (21.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.0 (21.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1239621.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Mean and standard deviation.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Comparison of cases and “noncases” after exposure to carbon monoxide.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>: COHb, carboxyhemoglobin.</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">Variable \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">Symptomatic (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21) \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">Asymptomatic (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10) \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"><span class="elsevierStyleItalic">p</span> \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 " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Sex</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (19.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (30.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.05 \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"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (80.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (70.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age (years)</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.7 (17.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.8 (22.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Smoker</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (10.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.05 \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"><span class="elsevierStyleHsp" style=""></span>No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (85.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (90.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Chronic diseases</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (30.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.05 \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"><span class="elsevierStyleHsp" style=""></span>No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (71.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (70.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">COHb (%)</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.3 (5.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.6 (3.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.05 \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"><span class="elsevierStyleItalic">Distance from the stove</span>, <span class="elsevierStyleItalic">m</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.0 (2.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.8 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>.05 \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"><span class="elsevierStyleItalic">Exposure time, min</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.3 (21.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.3 (21.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.036 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1239622.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Mean and standard deviation.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Comparison of confirmed symptomatic and asymptomatic cases (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>31) after exposure to carbon monoxide.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Carbon monoxide poisoning in patients presenting to the emergency department with a headache in winter months" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N. 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