Thromboembolic disease: Prophylaxis in the elderly?

Barba, R.

doi:10.1016/j.rceng.2013.01.001

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"apellidos" => "Barba" "email" => array:1 [ 0 => "raquel.barba@hospitalreyjuancarlos.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento Medicina Interna, Hospital Rey Juan Carlos, Móstoles, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo de Enfermedad Tromboembólica de la SEMI, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad tromboembólica: ¿Profilaxis en el anciano?" ] ] "textoCompleto" => "A 79-year-old male was sent to the emergency room from his retirement home for presenting abrupt dyspnea and palpitations. Four weeks earlier, he had been diagnosed with a urinary tract infection, hospitalized for 4 days, treated with intravenous ceftriaxone for 3 days and then treated with cefuroxime for an additional 10 days, with an acceptable evolution. During hospitalization, the patient received prophylaxis for thromboembolic disease, which was suspended on discharge. The patient did not report coughing, fever or chest pain.The patient had a history of hypertension treated with enalapril and had mild depressive symptoms treated with drugs. He had smoked 40 cigarettes per day since his youth. He had no history of bronchitis or previous symptoms of bronchial hyper-reactivity. He had worked as bricklayer and now required help with personal hygiene and supervision while dressing.This is a patient with a clinical picture of dyspnea and palpitations. The differential diagnosis should include the acute pulmonary embolism, pneumonia, asthma, heart failure and ischemic heart disease (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The absence of fever and other systemic symptoms does not correspond to an infectious clinical picture, although it does not completely rule it out.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In the physical examination, the patient was afebrile, with a blood pressure of 120/70mm Hg. Baseline oxygen saturation was 85%. His heart rate was 102 beats per minute. Auscultation did not reveal abnormalities; heart sounds were normal, there was no increase in jugular vein pressure, and the vesicular lung sounds were normal. The patient had no edemas or inflammation in the lower limbs.Laboratory tests showed no abnormalities in the hemogram. The results of the renal and hepatic function were normal. The C-reactive protein level was 21mg per liter. In the gasometry, the patient had a pH of 7.32, a pCO2 of 37mm Hg, and a pO2 of 47mm Hg. In the biochemistry, the patient presented a creatinine level of 1.1mg/dl, chloride of 105mEq/l, troponin of 0.52ng/ml and CPK of 27U/ml. Chest X-rays showed no abnormalities. In the ECG, the patient presented sinus tachycardia with no other relevant abnormalities.If his scale of risk for thromboembolic disease (TED) in the previous hospitalization is assessed according to the PRETEMED<a class="elsevierStyleCrossRef" href="#bib0005">1</a> guidelines (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), the patient scored 1 point for age, 1 point for smoking, 1 point for antidepressant treatment and 2 points for infection. The total of 5 points made the prescription of thromboprophylaxis advisable. Thromboprophylaxis reduces the risk of TED but does not eliminate it. Hypoxemia of this intensity in a patient with a normal pulmonary examination and radiography with no abnormalities leads us to suspect a pulmonary thromboembolism (PTE). The patient did not report obvious chest pain, and there were no abnormalities in the electrocardiogram that would suggest ischemic heart disease. The absence of fever, radiological abnormalities and leukocytosis also makes it less likely that there is an infectious clinical picture. The obstructive pulmonary disease may also cause hypoxemia with no radiographic abnormalities, but there were no clinical evidence or examination results for obstruction.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Given that PTE is the most likely diagnosis in a patient who has a history of immobilization, an objective test should be performed to confirm PTE. The use of clinical scales, such as the Wells<a class="elsevierStyleCrossRef" href="#bib0010">2</a> (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>) or Geneva<a class="elsevierStyleCrossRef" href="#bib0015">3</a> (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>), is advisable because these scales may help indicate which tests to perform and help interpret the results of the diagnostic tests. With the use of both scales, we can conclude that the patient has an intermediate risk of PTE (Wells scale [heart rate >100: 1.5 points; history of immobilization: 1.5 points, PTE more likely than other diseases: 3 points: total 6 points]; Geneva scale [age <80 years: 1 point; heart rate >100: 1 point, pCO2 35–40: 1 point, pO2 <50: 4 points: total 7 points]).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>For patients who have a low to moderate pretest probability of PTE, performing a D-dimer test is recommended as the next step in establishing the diagnosis. A negative result (less than 0.5mg/l, performed with a highly sensitive ELISA technique) allows us to rule out of the presence of circulating fibrin and precludes the diagnosis of VTE. The negativity of the test prevents the need to perform others tests in 30% of PTE cases. In this case, it would rule out the diagnosis (the NPV of a 94% negative D-dimer and the combined strategy of a moderate pretest probability with negative D-dimer has a NPV of 99%). In patients over 80 years of age, who are hospitalized, have cancer or are pregnant, the D-dimer test can be avoided because the D-dimer is usually increased.A D-dimer (ELISA method) test is performed that results in a value of 15mg/l (normal value <0.5mg/l), and therefore a helical CAT scan is requested. Numerous thrombi are observed in the pulmonary arteries, as is dilation of the right ventricle. How should this patient be studied and treated?The clinical issueAcute pulmonary embolism is a cause of severe complications and mortality associated with hospitalization. Thromboembolic disease (TED) is responsible for up to 15% of all in-hospital deaths. The definition of “thrombosis in hospitalized patients” includes patients in whom thrombosis is diagnosed during admission or in the 30 days following admission.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>TED remains a significant cause of morbidity and mortality in hospitalized patients<a class="elsevierStyleCrossRef" href="#bib0025">5</a> and is the most frequent cause of preventable mortality in hospitalized patients.<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> It has reached the point where the Agency for Healthcare Research and Quality (AHRQ) considers prophylaxis for preventing TED as the number one safe patient practice.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>Despite the evidence on the usefulness of prophylaxis in medical patients,<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a> it is known that a high percentage of patients who meet the criteria for receiving thromboprophylaxis do not receive it or do not maintain it long enough.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> The following problems have been detected in non-compliance with the prophylaxis<a class="elsevierStyleCrossRef" href="#bib0020">4</a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•An apparently greater heterogeneity among medical patients than among surgical patients,<a class="elsevierStyleCrossRef" href="#bib0050">10</a> which may hinder the identification of at-risk medical patients.</li><li class="elsevierStyleListItem" id="lsti0010">•A number of physicians believe that the evidence supporting prophylaxis studies in medical patients is not very strong.</li><li class="elsevierStyleListItem" id="lsti0015">•The risk of bleeding in patients is sometimes seen as a greater “threat” than thrombosis.</li><li class="elsevierStyleListItem" id="lsti0020">•The lack of departmental physicians with “expertise” in TED who can serve as consultants for questions on prophylaxis and the disease.</li><li class="elsevierStyleListItem" id="lsti0025">•The risk of TED is not routinely established.</li><li class="elsevierStyleListItem" id="lsti0030">•The risk of bleeding is not routinely established.</li><li class="elsevierStyleListItem" id="lsti0035">•The most appropriate prophylaxis for each risk level is not always well defined.</li><li class="elsevierStyleListItem" id="lsti0040">•There are differences and deviations among the risks for medical and surgical patients.</li><li class="elsevierStyleListItem" id="lsti0045">•There are different protocols in each unit.</li><li class="elsevierStyleListItem" id="lsti0050">•Prophylaxis is not properly applied with mechanical means.</li><li class="elsevierStyleListItem" id="lsti0055">•Patients are kept more immobilized than necessary.</li><li class="elsevierStyleListItem" id="lsti0060">•The risks of thrombosis and bleeding change during hospitalization but are not re-evaluated.</li><li class="elsevierStyleListItem" id="lsti0065">•When patients change departments, their anticoagulation treatment is sometimes not maintained.</li><li class="elsevierStyleListItem" id="lsti0070">•Prophylaxis is suspended when the patient is sent home.</li></ul>Hospitalized patients have an especially high risk of TED because they have a combination of chronic risk factors (for example, advanced age, heart failure, history of TED) with the associated acute risk of the condition causing hospitalisation.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a> Infections have been shown to be a risk factor for TED in hospitalized patients<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a> and outpatients.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Our patient had had a urinary tract infection that led to his hospitalization. At that time, the condition was considered an at-risk condition, and therefore the patient received thromboprophylaxis. However, the prophylaxis was withdrawn when the patient was discharged. Therefore, although the risk assessment was performed adequately, there was no consideration of the fact that the risk could last beyond the hospitalization period and that the patient might not recover his normal activity until after a few more days.A study performed in Minnesota on individuals institutionalized in a nursing home showed that one of the relevant risk factors in the development of TED was a return to the hospital, which multiplied by 5 the probability of developing a thrombosis.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> This fact reinforced the concept already stated by a number of authors that transitions between acute and chronic centers are an important opportunity to reduce the incidence of VTE.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> Up to 60% of patients who develop a thrombotic event in the community have a history of hospitalisation<a class="elsevierStyleCrossRefs" href="#bib0095">19,20</a> for medical and surgical reasons.The duration of the “thrombotic risk” is not well established. It is known that the greatest risk of VTE in surgical patients is produced in the initial weeks,<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a> but the time during which the risk is maintained is not well established. A study conducted in Scotland<a class="elsevierStyleCrossRef" href="#bib0110">22</a> on women who underwent surgery showed that the risk was high during the first six weeks, reaching its peak in the third week after the surgery. In a number of interventions, the risk extended for 12 additional weeks. Various studies have also shown the usefulness of extended prophylaxis in surgical patients.<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a> This had led to modifications in the guidelines, which, in some cases, recommend prolonging the postoperative prophylaxis for 4–5 weeks.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> The duration of prophylaxis in medical patients is also not well established.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> The only study that has assessed the usefulness of extended prophylaxis in medical patients is the EXCLAIM study.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> This study showed that medical patients over 75 years of age who were confined to a bed or armchair, and especially women, benefited from the maintenance of prophylaxis for four weeks.This patient does not strictly meet these criteria on account of being male. However, although four weeks are not fully indicated, there is evidence that four days are insufficient for an adequate prophylaxis. Although an inadequate duration of thromboprophylaxis is one of the keys to explaining the onset of TED, few studies have determined whether the recommended duration of the prophylaxis and the average stay of the patient are related.<a class="elsevierStyleCrossRefs" href="#bib0140">28,29</a> The ACCP recommendations<a class="elsevierStyleCrossRef" href="#bib0130">26</a> do not specify the duration of prophylaxis in medical patients. The NICE guidelines<a class="elsevierStyleCrossRef" href="#bib0125">25</a> indicate that prophylaxis should be maintained while the patient continues to be at risk for TED, without specifying a time, and the AHRQ guidelines<a class="elsevierStyleCrossRef" href="#bib0020">4</a> also do not specify a duration. The problem of short-duration prophylaxis as a risk factor for thrombosis has been detected by various authors and has been highlighted by the AHRQ<a class="elsevierStyleCrossRefs" href="#bib0020">4,28,29</a> as one of the problems in the failures of prophylaxis models in the majority of centers. However, we currently do not have any evidence as to what is the most appropriate duration for thromboprophylaxis in patients with medical pathologies.DiagnosisSymptoms such as dyspnea, chest pain, coughing, tachypnea, tachycardia, evidence of DVT and laboratory results such as hypoxemia and hypocapnia serve to provide diagnostic suspicion of PTE but have low specificity and sensitivity for diagnosis. Electrocardiographic and radiological data are also not very sensitive or specific, although they may provide a little help in supporting the diagnosis or its exclusion. The scales derived from the prediction rules that combine clinical data with predisposing data may be useful in determining the pretest probability of pulmonary embolism. The use of the Wells<a class="elsevierStyleCrossRef" href="#bib0010">2</a> or Geneva<a class="elsevierStyleCrossRef" href="#bib0015">3</a> scale is recommended because these scales may help in the subsequent steps when interpreting the results of the diagnostic tests.Performing a D-dimer test is recommended for patients with low to moderate probability. A negative result precludes the need to perform more diagnostic tests.<a class="elsevierStyleCrossRefs" href="#bib0015">3,30</a> However, the D-dimer test should not be requested for patients with a high probability of PTE because a negative result does not rule out these patients. The use of this test is also not recommended in patients over 80 years of age, who are hospitalized, who have cancer or who are pregnant because the concentrations tend to be nonspecifically high.Currently, when PTE is suspected, the most commonly used diagnostic test is the multislice CAT, which provides an accurate diagnosis in most cases<a class="elsevierStyleCrossRef" href="#bib0150">30</a> and, in addition, provides useful information on the size of the right ventricle. The majority of algorithms<a class="elsevierStyleCrossRef" href="#bib0015">3</a> use a combination of pretest probability, D-dimer and CAT. With this strategy, diagnostic decisions can be made in more than 98% of patients, with a PTE rate at 3 months of less than 1%.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>TreatmentAnticoagulation with heparin should be started without delay once the diagnosis of pulmonary embolism has been confirmed. If the diagnostic tests for patients with intermediate to high suspicion of PTE are going to be delayed, an initial dose should be prescribed while waiting for the results.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> Low molecular weight heparin is at least as effective as unfractionated heparin in the prevention of recurrence and just as safe in terms of potentially significant bleeding episodes. Treatment with heparin should be offered for at least 5–6 days in combination with oral anticoagulants until the INR is in the therapeutic range (2–3),<a class="elsevierStyleCrossRef" href="#bib0160">32</a> for at least two consecutive days. Fondaparinux, a selective inhibitor of factor Xa administered subcutaneously, does not require controls and is an alternative to low molecular weight heparins, especially in patients with severe renal failure. The new oral anticoagulants have proven their usefulness in the treatment of thromboembolism, although their role and the patients for whom they are indicated are yet to be defined.Conclusions and recommendationsPatients hospitalized in an acute care center due to an intercurrent process with TED risk factors who are discharged after a few days would probably benefit from maintaining the prophylaxis after being discharged. These patients should maintain the prophylaxis at least while they regain their abilities or the intercurrent disease has been resolved, or at least after completing 10 days (6–14 days) of the prophylaxis, which is the duration of the prophylaxis in clinical trials that has demonstrated efficacy in medical patients.<a class="elsevierStyleCrossRefs" href="#bib0060">12,33,34</a>The diagnostic strategy for patients with suspected TED should be based on calculating the clinical probability using validated scales. When the probability is low to intermediate, a negative D-dimer test (under 0.5mg/l) precludes the diagnosis and avoids more tests. If the result is positive, more tests are required, especially a multislice CAT. Patients with histories of hospitalization should be considered at-risk patients even if they have received prophylaxis during admission, especially if the duration of the anticoagulation was short." "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "The clinical issue" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Diagnosis" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Treatment" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions and recommendations" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-11-07" "fechaAceptado" => "2011-12-18" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Barba R. Enfermedad tromboembólica: ¿ profilaxis en el anciano? Rev Clin Esp. 2013;213:28–33." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "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=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary causes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bronchial hyper-reactivity (asthma, COPD) Pneumothorax \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary Embolism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pneumonia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiac causes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Decompensated heart failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ischemic heart disease (acute coronary syndrome) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arrhythmias (atrial fibrillation, flutter, supraventricular tachycardia) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiac tamponade \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Toxic-metabolic causes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe anemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CO poisoning \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Organophosphate poisoning \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other causes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sepsis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pleural effusion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Metabolic acidosis (lactic, methanol, ethylene glycol) Anxiety attack \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab53182.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Differential diagnosis." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:2 [ 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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Precipitating processes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pregnancy/postpartumAirplane flights >6h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Active intestinal inflammatory diseaseSevere acute infectionClass III heart failureNeoplasm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acute stroke with paralysis of lower limbsCOPD with severe decompensationAcute myocardial infarctionHeart failure IVMelanoma in chemotherapyIIM trauma without surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Associated processes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes mellitusHyperhomocysteinemiaHIV coinfectionLower limb paralysisPrevious VTE MSS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nephrotic syndromeThrombophiliaPrevious VTEVasculitis (Bechet/Wegener) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hormonal contraceptivesAntidepressantsAntipsychoticsAromatase inhibitorsTamoxifen-RaloxifeneHormone replacement therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chemotherapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central venous catheterAge >60 yearsObesity (BMI >28)Smoking >35 cigs/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bed rest >4 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab53184.png" ] ] 1 => 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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Adjusted risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider the use of physical measures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prophylaxis with LMWH is suggested \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prophylaxis with LMWH is recommended \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab53186.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Table for calculating the risk of thromboembolic disease in medical processes and indications for thromboprophylaxis: PRETEMED Guidelines.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>" ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "High probability: >6 points (40.6% have PTE).Moderate probability: 3–6 points (16.2% have PTE).Low probability: 0–2 points (1.3% have PTE)." "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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Clinical findings \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Points \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suspected deep vein thrombosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heart rate >100 beats×min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">History of thromboembolic disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immobilization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hemoptysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Active cancer (in treatment or treatment within the last 6 months, or palliative care) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PTE more likely than other diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total for the patient described \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab53185.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Calculation of the pretest probability of suffering a pulmonary thromboembolism (PTE) (Wells scale2)." ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "High probability: >9 points (81% have PTE).Moderate probability: 5–8 points (38% have PTE).Low probability: 0–4 points (10% have PTE).Figure algorithm for the diagnosis of pulmonary thromboembolism (PTE)." "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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Clinical findings \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Points \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age 60–79 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age ≥80 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">History of disease Thromboembolic disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recent surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heart rate >100 beats x minute \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">pCO2 <35mm Hg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">pCO2 35–40mm Hg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">pO2 <50mm Hg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">pO2 51–60mm Hg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">pO2 61–70mm Hg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">pO2 71–80mm Hg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Baseline atelectasis in chest X-rays \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Elevation of the hemidiaphragm in chest X-rays \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total for the patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab53183.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Calculation of the pretest probability of suffering a pulmonary thromboembolism (PTE) (Geneva scale3)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:34 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guía PRETEMED -2007 sobre prevención de enfermedad tromboembólica venosa en patología médica" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F.J. 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Chest X-rays showed no abnormalities&#46; In the ECG&#44; the patient presented sinus tachycardia with no other relevant abnormalities&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">If his scale of risk for thromboembolic disease &#40;TED&#41; in the previous hospitalization is assessed according to the PRETEMED<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> guidelines &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; the patient scored 1 point for age&#44; 1 point for smoking&#44; 1 point for antidepressant treatment and 2 points for infection&#46; The total of 5 points made the prescription of thromboprophylaxis advisable&#46; Thromboprophylaxis reduces the risk of TED but does not eliminate it&#46; Hypoxemia of this intensity in a patient with a normal pulmonary examination and radiography with no abnormalities leads us to suspect a pulmonary thromboembolism &#40;PTE&#41;&#46; The patient did not report obvious chest pain&#44; and there were no abnormalities in the electrocardiogram that would suggest ischemic heart disease&#46; The absence of fever&#44; radiological abnormalities and leukocytosis also makes it less likely that there is an infectious clinical picture&#46; The obstructive pulmonary disease may also cause hypoxemia with no radiographic abnormalities&#44; but there were no clinical evidence or examination results for obstruction&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Given that PTE is the most likely diagnosis in a patient who has a history of immobilization&#44; an objective test should be performed to confirm PTE&#46; The use of clinical scales&#44; such as the Wells<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; or Geneva<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#44; is advisable because these scales may help indicate which tests to perform and help interpret the results of the diagnostic tests&#46; With the use of both scales&#44; we can conclude that the patient has an intermediate risk of PTE &#40;Wells scale &#91;heart rate &#62;100&#58; 1&#46;5 points&#59; history of immobilization&#58; 1&#46;5 points&#44; PTE more likely than other diseases&#58; 3 points&#58; total 6 points&#93;&#59; Geneva scale &#91;age &#60;80 years&#58; 1 point&#59; heart rate &#62;100&#58; 1 point&#44; pCO<span class="elsevierStyleInf">2</span> 35&#8211;40&#58; 1 point&#44; pO<span class="elsevierStyleInf">2</span> &#60;50&#58; 4 points&#58; total 7 points&#93;&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">For patients who have a low to moderate pretest probability of PTE&#44; performing a D-dimer test is recommended as the next step in establishing the diagnosis&#46; A negative result &#40;less than 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#44; performed with a highly sensitive ELISA technique&#41; allows us to rule out of the presence of circulating fibrin and precludes the diagnosis of VTE&#46; The negativity of the test prevents the need to perform others tests in 30&#37; of PTE cases&#46; In this case&#44; it would rule out the diagnosis &#40;the NPV of a 94&#37; negative D-dimer and the combined strategy of a moderate pretest probability with negative D-dimer has a NPV of 99&#37;&#41;&#46; In patients over 80 years of age&#44; who are hospitalized&#44; have cancer or are pregnant&#44; the D-dimer test can be avoided because the D-dimer is usually increased&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A D-dimer &#40;ELISA method&#41; test is performed that results in a value of 15<span class="elsevierStyleHsp" style=""></span>mg&#47;l &#40;normal value &#60;0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#41;&#44; and therefore a helical CAT scan is requested&#46; Numerous thrombi are observed in the pulmonary arteries&#44; as is dilation of the right ventricle&#46; How should this patient be studied and treated&#63;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The clinical issue</span><p id="par0050" class="elsevierStylePara elsevierViewall">Acute pulmonary embolism is a cause of severe complications and mortality associated with hospitalization&#46; Thromboembolic disease &#40;TED&#41; is responsible for up to 15&#37; of all in-hospital deaths&#46; The definition of &#8220;thrombosis in hospitalized patients&#8221; includes patients in whom thrombosis is diagnosed during admission or in the 30 days following admission&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">TED remains a significant cause of morbidity and mortality in hospitalized patients<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and is the most frequent cause of preventable mortality in hospitalized patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> It has reached the point where the <span class="elsevierStyleItalic">Agency for Healthcare Research and Quality</span> &#40;AHRQ&#41; considers prophylaxis for preventing TED as the number one safe patient practice&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Despite the evidence on the usefulness of prophylaxis in medical patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> it is known that a high percentage of patients who meet the criteria for receiving thromboprophylaxis do not receive it or do not maintain it long enough&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The following problems have been detected in non-compliance with the prophylaxis<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">An apparently greater heterogeneity among medical patients than among surgical patients&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> which may hinder the identification of at-risk medical patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">A number of physicians believe that the evidence supporting prophylaxis studies in medical patients is not very strong&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">The risk of bleeding in patients is sometimes seen as a greater &#8220;threat&#8221; than thrombosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">The lack of departmental physicians with &#8220;expertise&#8221; in TED who can serve as consultants for questions on prophylaxis and the disease&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">The risk of TED is not routinely established&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">The risk of bleeding is not routinely established&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">The most appropriate prophylaxis for each risk level is not always well defined&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">There are differences and deviations among the risks for medical and surgical patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">There are different protocols in each unit&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Prophylaxis is not properly applied with mechanical means&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Patients are kept more immobilized than necessary&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">The risks of thrombosis and bleeding change during hospitalization but are not re-evaluated&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">When patients change departments&#44; their anticoagulation treatment is sometimes not maintained&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Prophylaxis is suspended when the patient is sent home&#46;</p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">Hospitalized patients have an especially high risk of TED because they have a combination of chronic risk factors &#40;for example&#44; advanced age&#44; heart failure&#44; history of TED&#41; with the associated acute risk of the condition causing hospitalisation&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> Infections have been shown to be a risk factor for TED in hospitalized patients<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> and outpatients&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Our patient had had a urinary tract infection that led to his hospitalization&#46; At that time&#44; the condition was considered an at-risk condition&#44; and therefore the patient received thromboprophylaxis&#46; However&#44; the prophylaxis was withdrawn when the patient was discharged&#46; Therefore&#44; although the risk assessment was performed adequately&#44; there was no consideration of the fact that the risk could last beyond the hospitalization period and that the patient might not recover his normal activity until after a few more days&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">A study performed in Minnesota on individuals institutionalized in a nursing home showed that one of the relevant risk factors in the development of TED was a return to the hospital&#44; which multiplied by 5 the probability of developing a thrombosis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> This fact reinforced the concept already stated by a number of authors that transitions between acute and chronic centers are an important opportunity to reduce the incidence of VTE&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Up to 60&#37; of patients who develop a thrombotic event in the community have a history of hospitalisation<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> for medical and surgical reasons&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The duration of the &#8220;thrombotic risk&#8221; is not well established&#46; It is known that the greatest risk of VTE in surgical patients is produced in the initial weeks&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> but the time during which the risk is maintained is not well established&#46; A study conducted in Scotland<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> on women who underwent surgery showed that the risk was high during the first six weeks&#44; reaching its peak in the third week after the surgery&#46; In a number of interventions&#44; the risk extended for 12 additional weeks&#46; Various studies have also shown the usefulness of extended prophylaxis in surgical patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> This had led to modifications in the guidelines&#44; which&#44; in some cases&#44; recommend prolonging the postoperative prophylaxis for 4&#8211;5 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The duration of prophylaxis in medical patients is also not well established&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The only study that has assessed the usefulness of extended prophylaxis in medical patients is the EXCLAIM study&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> This study showed that medical patients over 75 years of age who were confined to a bed or armchair&#44; and especially women&#44; benefited from the maintenance of prophylaxis for four weeks&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">This patient does not strictly meet these criteria on account of being male&#46; However&#44; although four weeks are not fully indicated&#44; there is evidence that four days are insufficient for an adequate prophylaxis&#46; Although an inadequate duration of thromboprophylaxis is one of the keys to explaining the onset of TED&#44; few studies have determined whether the recommended duration of the prophylaxis and the average stay of the patient are related&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a> The ACCP recommendations<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> do not specify the duration of prophylaxis in medical patients&#46; The NICE guidelines<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> indicate that prophylaxis should be maintained while the patient continues to be at risk for TED&#44; without specifying a time&#44; and the AHRQ guidelines<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> also do not specify a duration&#46; The problem of short-duration prophylaxis as a risk factor for thrombosis has been detected by various authors and has been highlighted by the AHRQ<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;28&#44;29</span></a> as one of the problems in the failures of prophylaxis models in the majority of centers&#46; However&#44; we currently do not have any evidence as to what is the most appropriate duration for thromboprophylaxis in patients with medical pathologies&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0155" class="elsevierStylePara elsevierViewall">Symptoms such as dyspnea&#44; chest pain&#44; coughing&#44; tachypnea&#44; tachycardia&#44; evidence of DVT and laboratory results such as hypoxemia and hypocapnia serve to provide diagnostic suspicion of PTE but have low specificity and sensitivity for diagnosis&#46; Electrocardiographic and radiological data are also not very sensitive or specific&#44; although they may provide a little help in supporting the diagnosis or its exclusion&#46; The scales derived from the prediction rules that combine clinical data with predisposing data may be useful in determining the pretest probability of pulmonary embolism&#46; The use of the Wells<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> or Geneva<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> scale is recommended because these scales may help in the subsequent steps when interpreting the results of the diagnostic tests&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Performing a D-dimer test is recommended for patients with low to moderate probability&#46; A negative result precludes the need to perform more diagnostic tests&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;30</span></a> However&#44; the D-dimer test should not be requested for patients with a high probability of PTE because a negative result does not rule out these patients&#46; The use of this test is also not recommended in patients over 80 years of age&#44; who are hospitalized&#44; who have cancer or who are pregnant because the concentrations tend to be nonspecifically high&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Currently&#44; when PTE is suspected&#44; the most commonly used diagnostic test is the multislice CAT&#44; which provides an accurate diagnosis in most cases<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> and&#44; in addition&#44; provides useful information on the size of the right ventricle&#46; The majority of algorithms<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> use a combination of pretest probability&#44; D-dimer and CAT&#46; With this strategy&#44; diagnostic decisions can be made in more than 98&#37; of patients&#44; with a PTE rate at 3 months of less than 1&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Treatment</span><p id="par0170" class="elsevierStylePara elsevierViewall">Anticoagulation with heparin should be started without delay once the diagnosis of pulmonary embolism has been confirmed&#46; If the diagnostic tests for patients with intermediate to high suspicion of PTE are going to be delayed&#44; an initial dose should be prescribed while waiting for the results&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Low molecular weight heparin is at least as effective as unfractionated heparin in the prevention of recurrence and just as safe in terms of potentially significant bleeding episodes&#46; Treatment with heparin should be offered for at least 5&#8211;6 days in combination with oral anticoagulants until the INR is in the therapeutic range &#40;2&#8211;3&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> for at least two consecutive days&#46; Fondaparinux&#44; a selective inhibitor of factor Xa administered subcutaneously&#44; does not require controls and is an alternative to low molecular weight heparins&#44; especially in patients with severe renal failure&#46; The new oral anticoagulants have proven their usefulness in the treatment of thromboembolism&#44; although their role and the patients for whom they are indicated are yet to be defined&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions and recommendations</span><p id="par0175" class="elsevierStylePara elsevierViewall">Patients hospitalized in an acute care center due to an intercurrent process with TED risk factors who are discharged after a few days would probably benefit from maintaining the prophylaxis after being discharged&#46; These patients should maintain the prophylaxis at least while they regain their abilities or the intercurrent disease has been resolved&#44; or at least after completing 10 days &#40;6&#8211;14 days&#41; of the prophylaxis&#44; which is the duration of the prophylaxis in clinical trials that has demonstrated efficacy in medical patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;33&#44;34</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The diagnostic strategy for patients with suspected TED should be based on calculating the clinical probability using validated scales&#46; When the probability is low to intermediate&#44; a negative D-dimer test &#40;under 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#41; precludes the diagnosis and avoids more tests&#46; If the result is positive&#44; more tests are required&#44; especially a multislice CAT&#46; Patients with histories of hospitalization should be considered at-risk patients even if they have received prophylaxis during admission&#44; especially if the duration of the anticoagulation was short&#46;</p></span></span>"
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          "identificador" => "sec0005"
          "titulo" => "The clinical issue"
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        3 => array:2 [
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    "fechaAceptado" => "2011-12-18"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Barba R&#46; Enfermedad tromboemb&#243;lica&#58; &#191; profilaxis en el anciano&#63; Rev Clin Esp&#46; 2013&#59;213&#58;28&#8211;33&#46;</p>"
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Other causes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pleural effusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Metabolic acidosis &#40;lactic&#44; methanol&#44; ethylene glycol&#41; Anxiety attack&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab53182.png"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Differential diagnosis&#46;</p>"
        ]
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Precipitating processes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pregnancy&#47;postpartumAirplane flights &#62;6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Active intestinal inflammatory diseaseSevere acute infectionClass III heart failureNeoplasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acute stroke with paralysis of lower limbsCOPD with severe decompensationAcute myocardial infarctionHeart failure IVMelanoma in chemotherapyIIM trauma without surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Associated processes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes mellitusHyperhomocysteinemiaHIV coinfectionLower limb paralysisPrevious VTE MSS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nephrotic syndromeThrombophiliaPrevious VTEVasculitis &#40;Bechet&#47;Wegener&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hormonal contraceptivesAntidepressantsAntipsychoticsAromatase inhibitorsTamoxifen-RaloxifeneHormone replacement therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chemotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central venous catheterAge &#62;60 yearsObesity &#40;BMI &#62;28&#41;Smoking &#62;35 cigs&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bed rest &#62;4 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab53184.png"
              ]
            ]
            1 => 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"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Adjusted risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#8211;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consider the use of physical measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prophylaxis with LMWH is suggested&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prophylaxis with LMWH is recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Table for calculating the risk of thromboembolic disease in medical processes and indications for thromboprophylaxis&#58; PRETEMED Guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">High probability&#58; &#62;6 points &#40;40&#46;6&#37; have PTE&#41;&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Moderate probability&#58; 3&#8211;6 points &#40;16&#46;2&#37; have PTE&#41;&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Low probability&#58; 0&#8211;2 points &#40;1&#46;3&#37; have PTE&#41;&#46;</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"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical findings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Points&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Suspected deep vein thrombosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heart rate &#62;100 beats<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">History of thromboembolic disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immobilization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemoptysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Active cancer &#40;in treatment or treatment within the last 6 months&#44; or palliative care&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PTE more likely than other diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total for the patient described&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab53185.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Calculation of the pretest probability of suffering a pulmonary thromboembolism &#40;PTE&#41; &#40;Wells scale2&#41;&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">High probability&#58; &#62;9 points &#40;81&#37; have PTE&#41;&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Moderate probability&#58; 5&#8211;8 points &#40;38&#37; have PTE&#41;&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Low probability&#58; 0&#8211;4 points &#40;10&#37; have PTE&#41;&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Figure algorithm for the diagnosis of pulmonary thromboembolism &#40;PTE&#41;&#46;</p>"
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                  \t\t\t\t">Heart rate &#62;100 beats x minute&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">pCO<span class="elsevierStyleInf">2</span> &#60;35<span class="elsevierStyleHsp" style=""></span>mm Hg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">pO<span class="elsevierStyleInf">2</span> 51&#8211;60<span class="elsevierStyleHsp" style=""></span>mm Hg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">pO<span class="elsevierStyleInf">2</span> 61&#8211;70<span class="elsevierStyleHsp" style=""></span>mm Hg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">pO<span class="elsevierStyleInf">2</span> 71&#8211;80<span class="elsevierStyleHsp" style=""></span>mm Hg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">Elevation of the hemidiaphragm in chest X-rays&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Total for the patient&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Calculation of the pretest probability of suffering a pulmonary thromboembolism &#40;PTE&#41; &#40;Geneva scale3&#41;&#46;</p>"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Gu&#237;a PRETEMED -2007 sobre prevenci&#243;n de enfermedad tromboemb&#243;lica venosa en patolog&#237;a m&#233;dica"
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                        0 => array:2 [
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                            2 => "S&#46; Vidal Serrano"
                            3 => "C&#46; Alonso Ortiz del R&#237;o"
                            4 => "R&#46; Guti&#233;rrez Tous"
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                0 => array:2 [
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                      "titulo" => "Excluding pulmonary embolism at the bedside without diagnostic imaging&#58; management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;S&#46; Wells"
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                            2 => "M&#46; Rodger"
                            3 => "I&#46; Stiell"
                            4 => "J&#46;F&#46; Dreyer"
                            5 => "D&#46; Barnes"
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Annals of Internal Medicine"
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                        "paginaInicial" => "98"
                        "paginaFinal" => "107"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11453709"
                            "web" => "Medline"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prediction of pulmonary embolism in the emergency department&#58; the revised Geneva score"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46;G&#46; Le"
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                            2 => "P&#46;M&#46; Roy"
                            3 => "O&#46; Sanchez"
                            4 => "D&#46; Aujesky"
                            5 => "H&#46; Bounameaux"
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                      "Revista" => array:6 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Preventing Hospital-Adquired Venous Thromboembolism&#58; A Guide for Effective Quality Improvement"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "G&#46; Maynard"
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                    0 => array:1 [
                      "Libro" => array:3 [
                        "titulo" => "In&#58; Agency for Healthcare Research and Quality&#44; editor"
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                        "editorial" => "Rockville"
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              "etiqueta" => "5"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Riesgo de enfermedad tromboemb&#243;lica y estudio de la utilizaci&#243;n de tromboprofilaxis en pacientes m&#233;dicos hospitalizados y al alta hospitalaria"
                      "autores" => array:1 [
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                            0 => "A&#46;M&#46; Borobia"
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                            2 => "A&#46;N&#46; Iniesta"
                            3 => "P&#46; Garc&#237;a de Paso"
                            4 => "J&#46; Valero Recio"
                            5 => "M&#46; Bizighescu"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Revista Clinica Espanola"
                        "fecha" => "2009"
                        "volumen" => "209"
                        "paginaInicial" => "15"
                        "paginaFinal" => "20"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19268092"
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                    0 => array:2 [
                      "titulo" => "Estimated incidence of acute pulmonary embolism in a community&#47;teaching general hospital"
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                          "etal" => true
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                            0 => "P&#46;D&#46; Stein"
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                            2 => "N&#46;K&#46; Kalra"
                            3 => "M&#46; Petrina"
                            4 => "P&#46; Savarapu"
                            5 => "J&#46;W&#46; Furlong Jr"
                          ]
                        ]
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