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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sickle cell disease is a multisystemic condition&#44; and splenic complications are among its most prominent manifestations&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Spleen enlargement is common in the first decade of life&#44; but vascular occlusive events and recurrent splenic infarctions lead to autosplenectomy&#46; However&#44; splenomegaly persists in some patients to later ages&#44; and other patients require splenectomy for various reasons&#44; such as recurrent splenic sequestration crises &#40;SSCs&#41;&#44; hypersplenism&#44; massive splenic infarction&#44; and splenic abscess&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The most common indication for splenectomy in sickle cell disease is SSC&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Total splenectomy is the classical treatment for SSC in children older than 4 years&#44; but the procedure often carries a high risk of fulminant septicaemia&#44; which may be fatal&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The risk is greater in younger children&#44; in whom the preferred approach is a transfusion regime until at least 2 years of age&#46; Aiming to avoid or reduce the adverse effects of total splenectomy&#44; the Institute of Haematology and Inmunology &#40;IHI&#41; started to perform partial splenectomies in 1986&#44; with excellent results&#46; The remaining spleen remains functional&#44; at least partially&#44; for a period of time that has yet to be determined&#44; and SSCs do not recur&#44; which supports the indication of partial splenectomy in patients with sickle cell disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#8211;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">For a long time&#44; total splenectomy was only associated to increased risk of overwhelming infections&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Recent publications have described an increased incidence of vaso-occlusive pain crises &#40;VOPCs&#41;&#44; acute chess syndrome &#40;ACS&#41;&#44; and stroke following total splenectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Today it is also associated with thrombotic complications&#44; such as deep-venous thrombosis&#44; especially portal venous thrombosis&#44; and with pulmonary hypertension &#40;PHT&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a> These and other complications have not been reported in patients with partial splenectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#8211;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Due to all the risks currently known to be associated with total splenectomy&#44; there is a growing interest in partial splenectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The aim of this study was to characterise the clinical and laboratory features of patients with sickle cell disease that had undergone partial splenectomy&#44; and to compare them with those of non-splenectomised patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We performed an observational&#44; retrospective&#44; comparative study in patients with sickle cell disease who received ongoing care at the haemoglobinopathies clinic of the IHI between September 2010 and December 2011&#46; The source population consisted of patients with sickle cell disease receiving care at the paediatric and adult departments of the IHI&#46; From it we selected a group of patients aged 1&#8211;18 years who had undergone a partial splenectomy&#46; We excluded patients who did not want to participate or whose parents or guardians did not give consent&#44; and patients whose records did not include any postoperative clinical data&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study included 54 splenectomised patients&#44; so we selected a comparative group of non-splenectomised patients with similar characteristics &#40;age&#44; sex&#44; type of haemoglobinopathy&#41; subject to the same exclusion criteria&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We reviewed the medical histories to collect demographic data and postoperative clinical data pertaining to sickle cell disease&#46; We calculated the annual mean counts of haemoglobin&#44; reticulocytes&#44; leukocytes&#44; neutrophils&#44; and platelets&#44; for both before and 6 months after splenectomy&#46; We recorded baseline values for patients &#40;when they had been without transfusions for at least 3 months and without acute clinical events for at least 1 month&#41;&#46; In the group of non-splenectomised patients&#44; the data were collected starting at age 4&#46;1 years&#44; which is the mean age at which patients were splenectomised&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We analysed cerebral blood flow &#40;CBF&#41; measured by transcranial Doppler ultrasound&#44; and values of tricuspid regurgitant jet velocity &#40;TRJV&#41; obtained by echocardiography after splenectomy&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We expressed qualitative variables as absolute and relative frequencies&#46; We analysed them using the Chi-squared test&#44; and calculated the odds ratio &#40;OR&#41;&#46; Quantitative variables were summarised as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#44; and analysed using ANOVA for comparing means and Student&#39;s t test for matched pairs&#46; We determined the frequency of events per 100 patients per year&#46; The data were analysed with the statistical software SPSS version 12&#46;0&#46;0&#46; We set the confidence level at 95&#37; and the statistical significance at <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#46;05 for all the tests performed&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Ethical considerations</span><p id="par0050" class="elsevierStylePara elsevierViewall">We adhered to the ethical principles of the Helsinki Declaration&#46; We asked all parents&#44; guardians&#44; and patients for informed consent&#46; The study protocol was reviewed and approved by the ethics committee and the scientific board of our hospital&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">The study included a total of 54 patients that underwent partial splenectomy&#44; and 54 non-splenectomised patients&#46; Patients with sickle cell anaemia accounted for 70&#46;4&#37; of the splenectomies&#44; HbS&#946;<span class="elsevierStyleSup">0</span> thalassaemia patients for 20&#46;4&#37;&#44; and HbS&#946;<span class="elsevierStyleSup">&#43;</span> thalassaemia patients for 9&#46;3&#37;&#46; Male patients predominated in both groups&#44; accounting for 66&#46;7&#37; of splenectomised patients&#46; The mean age was 15&#46;1 years &#40;range&#44; 1&#46;7&#8211;33&#46;7 years&#41; and the duration of follow-up in the clinic was 9&#46;6 years for the group of splenectomised patients&#46; The groups were comparable &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The indication for performing a partial splenectomy was hypersplenism in 7&#46;4&#37; of the operated patients&#44; at a mean age of 7&#46;4 years &#40;range&#44; 2&#46;6&#8211;15&#46;4 years&#41;&#44; and recurrent splenic sequestration in the remaining patients &#40;92&#46;6&#37;&#41; at a mean age of 3&#46;8 years &#40;range&#44; 0&#46;9&#8211;13&#46;8 years&#41;&#46; The mean age at the time of splenectomy for all patients was 4&#46;1 years&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Postoperative complications developed in 33&#46;4&#37; of the splenectomised patients&#46; The most frequent complications were fever without source &#40;14&#46;8&#37;&#41; and ACS &#40;11&#46;1&#37;&#41;&#46; Sepsis developed in 3&#46;7&#37; of these patients&#44; surgical site infections in 1&#46;9&#37;&#44; and subphrenic abscess in another 1&#46;9&#37;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the comparison of haematological variables in patients before and after splenectomy&#46; Following surgery&#44; there was a significant increase &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; in leukocytes &#40;from 9&#46;9 to 11&#46;4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#41;&#44; platelets &#40;from 270&#46;1 to 386&#46;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#41;&#44; and neutrophils &#40;from 4&#46;1 to 5&#46;4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#41;&#46; Although the increase was not significant&#44; mean haemoglobin rose from 7&#46;55 to 7&#46;86<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;227&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The comparison of haematological variables between splenectomised and non-splenectomised patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; showed a significant increase in the neutrophil count &#40;5&#46;4 vs 4&#46;8<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;026&#41; and platelet count &#40;386&#46;1 vs 342&#46;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;002&#41; of operated patients&#46; In splenectomised patients&#44; the mean leucocyte count was 11&#46;4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#44; and in non-splenectomised patients it was 10&#46;6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;060&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the number of events per 100 patients per year&#44; with similar means found in splenectomised patients compared to non-splenectomised patients&#58; infections &#40;29&#46;0 vs 25&#46;6&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;559&#41;&#44; VOPC &#40;56&#46;7 vs 53&#46;4&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;821&#41;&#44; ACS &#40;14&#46;7 vs 12&#46;9&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;560&#41;&#44; hospital admissions &#40;53&#46;7 vs 40&#46;9&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;246&#41;&#44; and transfusions &#40;39&#46;8 vs 29&#46;1&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;377&#41;&#46; The increase was not statistically significant&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> compares the frequency of other clinical events&#46; Hepatic sequestration crises occurred in 14 &#40;25&#46;9&#37;&#41; of the splenectomised patients&#44; a finding that was statistically significant &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;041&#41;&#46; This clinical event did not appear in either group before age 4&#46;1 years&#46; The differences in the rest of the analysed clinical events were not significant&#46; The mean incidence of SSC was 4&#46;0 before splenectomy&#44; and this clinical event did not appear after surgery&#46; In non-splenectomised patients&#44; the mean incidence of SSC was 0&#46;54 before age 4&#46;1 years&#44; and 0&#46;11 after&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> shows that the prevalence of a TRJV of 2&#46;5<span class="elsevierStyleHsp" style=""></span>m&#47;s or greater was of 31&#46;8&#37; in splenectomised patients compared to 23&#46;5&#37; in non-splenectomised patients &#40;OR<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>1&#46;51&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;56&#41;&#46; The mean TRJV was 2&#46;16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;43<span class="elsevierStyleHsp" style=""></span>m&#47;s in splenectomised patients&#44; and 1&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;46<span class="elsevierStyleHsp" style=""></span>m&#47;s in non-splenectomised patients&#46; The CBF velocity measured by transcranial Doppler ultrasound was 170<span class="elsevierStyleHsp" style=""></span>cm&#47;s or greater in 23&#46;5&#37; of splenectomised patients&#44; while these velocities were only seen in 8&#46;8&#37; of non-splenectomised patients &#40;OR<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>3&#46;18&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;09&#41;&#46; The mean CBF velocity was 137&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>35&#46;4<span class="elsevierStyleHsp" style=""></span>cm&#47;s in splenectomised patients&#44; and 122&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>35&#46;7<span class="elsevierStyleHsp" style=""></span>cm&#47;s in non-splenectomised patients&#46; These results approached statistical significance &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;09&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">At the IHI&#44; partial splenectomy is a safe and effective procedure for children with sickle cell disease who require it&#44; thanks to advances in immunoprophylaxis&#44; accrued knowledge in the management of the disease&#44; and the experience gained in partial splenectomy since 1986&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Most splenectomised patients had sickle cell anaemia&#44; the most prevalent type of sickle cell disease in Cuba&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> which is also the most severe form of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Following in frequency were patients with HbS&#946;<span class="elsevierStyleSup">0</span> thalassaemia&#44; which is the third most prevalent haemoglobinopathy in Cuba&#44; but has a severe clinical course that cannot be discerned from that of sickle cell anaemia&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> so that its manifestations are analysed in combination with those of sickle cell anaemia in most studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The mean duration of follow-up after splenectomy was 9&#46;6 years&#44; which was similar to follow-up in the non-splenectomy group&#44; a fact that allowed us to make a broader characterisation of the disease&#46; Duration of follow-up is shorter in international studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;8&#44;9&#44;16</span></a> We only found 1 study with comparative groups of non-splenectomised patients and patients who had undergone total splenectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The average age at which splenectomy is performed for SSC ranges from 2&#46;7 to 7&#46;6 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;8&#44;18</span></a> In our study&#44; the mean age was 3&#46;8 years&#44; with a slightly broader range of 0&#46;9&#8211;13&#46;8 years&#46; At the IHI&#44; partial splenectomy is performed after 2 years of age in patients who have had 2 splenic sequestration events&#46; Before this age&#44; patients are treated with a hypertransfusion regime&#46; Partial splenectomy was performed in 13 &#40;24&#37;&#41; patients before 2 years of age&#44; a figure that corresponded to approximately half the cases reported by Kalpatthi et al&#46; for this age group&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The indications for the procedure were very severe&#44; life-threatening recurrent SSCs that occurred despite the hypertransfusion regime&#44; and early alloimmunisation in 1 patient&#46; The latter child underwent splenectomy before age 1 year because he became alloimmunised against 3 erythrocyte antibodies &#40;C&#44; E&#44; Fya&#41; in the first month of the hypertransfusion regime&#46; These antigens are more frequent in the Caucasian patients that constitute the majority of donors in Cuba&#44; which is the main reason why patients with sickle cell disease become alloimmunised&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The 13-year-old patient who underwent partial splenectomy had sickle cell anaemia and was being treated with hydroxyurea&#46; Ninety-four percent of patients with sickle cell anaemia progress to functional autosplenectomy by around 5 years of age&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> but patients treated with hydroxyurea may maintain splenic function for longer&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;21</span></a> This could account for the recurrent SSCs in older patients&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The mean age of the children who underwent splenectomy for hypersplenism was 7&#46;4 years&#46; Three of the 4 patients splenectomised for hypersplenism were patients with HbS&#946; thalassaemia&#44; 2 of them with S&#946;<span class="elsevierStyleSup">0</span> thalassaemia&#46; Splenectomy in patients with hypersplenism resulted in reduced need for transfusions and removed the intra-abdominal pressure exerted by the enlarged spleen&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Around 20&#8211;30&#37; of patients with sickle cell disease develop postoperative complications&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> One of the most frequent immediate complications is ACS&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;8&#44;16&#44;22</span></a> In our study&#44; 33&#46;4&#37; of patients developed postoperative complications&#44; and had a favourable outcome&#46; The most frequent complications were fever of unknown source and ACS&#46; Laparoscopic total splenectomy is associated to a shorter hospital stay and the same postoperative complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;18&#44;23</span></a> Recently&#44; there have been reports of laparoscopic partial splenectomy procedures in patients with hereditary spherocytosis&#44; sickle cell disease&#44; and focal splenic tumours&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;24&#44;25</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Our study found a significant increase in platelets and leukocytes after splenectomy&#46; These results are consistent with the findings of other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;8&#44;9</span></a> Patients with recurrent SSCs may have a degree of hypersplenism&#44; which would account for the increase in platelet and leucocyte counts following splenectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Kalpatthi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> did not find significant changes in the haemoglobin and reticulocyte counts from before and after total splenectomy&#46; The results of our study were consistent with this&#46; A study of patients with sickle cell anaemia and recurrent SSC found a significant increase in the neutrophil count after total splenectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In our study&#44; the results of patients with partial splenectomy were similar&#46; The studies on partial splenectomy that we reviewed did not compare haematological variables of splenectomised an non-splenectomised patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;26</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Recent studies describe a higher incidence of VOPC&#44; ACS&#44; and stroke in patients with total splenectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9&#44;17</span></a> Other authors suggest that this difference may be due to increased blood viscosity due to leukocytosis and thrombocytosis&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Yet others believe it is part of the natural course of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However&#44; Wright et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> compared a group of patients with total splenectomy with a non-splenectomised control group&#44; and found a significantly higher incidence of VOPC and ACS in splenectomised patients&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In this study&#44; clinical events in splenectomised patients were not significantly different from those in the comparison group&#44; although we found a slightly higher average number of infections&#44; VOPC&#44; hospital admissions&#44; and transfusions in the former group&#46; However&#44; there was a significant increase in hepatic sequestration crisis &#40;HSC&#41; after partial splenectomy compared to non-splenectomised patients&#46; It is likely that SSC and HSC have the same pathophysiological basis&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Patients with sickle cell disease are in a chronic prothrombotic state that is exacerbated during acute vaso-occlusive events&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Current evidence shows that patients with haemolytic anaemias are at higher risk for thromboembolic complications&#44; especially after total splenectomy&#46; The higher frequency of these complications may be due to the greater number of circulating microparticles and of erythrocytes that expose phosphatidylserine on their surface&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;27</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The clinical manifestations of thrombophilia in sickle cell disease include venous thromboembolism&#44; in situ pulmonary thrombosis&#44; and stroke&#44; all of which are more frequent in patients who have undergone total splenectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> However&#44; we did not find significant differences between the 2 groups&#44; either in thrombotic events or in stroke&#44; which suggests that the splenic remnant may protect against these complications&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In the context of our study&#44; partial splenectomy was not associated to the development of leg ulcers and priapism&#44; vascular complications that are frequent in sickle cell disease and correlate to the severity of haemolysis&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> but we must take into account that leg ulcers are rare in children&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Total splenectomy is a risk factor for the development of PHT&#46; In patients with beta thalassaemia&#44; PHT has a high prevalence of up to 70&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The prevalence in sickle cell disease is about 30&#37; when echocardiography is used as a diagnostic method&#44; determining the TRJV to estimate the pulmonary artery pressure&#44; but it has not been studied in splenectomised patients&#46; A TRJV of 2&#46;5<span class="elsevierStyleHsp" style=""></span>m&#47;s or greater is associated with a poor prognosis in several studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;19</span></a> In our study&#44; a TRJV of 2&#46;5<span class="elsevierStyleHsp" style=""></span>m&#47;s or greater was 1&#46;51 times more prevalent in splenectomised patients&#44; although this difference was not significant&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">One of the predictors of stroke is cerebral blood flow velocity measured by transcranial Doppler ultrasonography&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> We found no difference in the incidence of stroke between the two groups of patients in our study&#59; however&#44; alterations in cerebral blood flow velocity were 3&#46;18 times more frequent in splenectomised patients than in non-splenectomised patients&#44; a difference that neared statistical significance&#46; These results are consistent with what has been reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The greater frequency of cerebral flow abnormalities in splenectomised patients could be a risk factor for stroke&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">This study allowed us to increase our knowledge of the clinical and haematological changes that occur in patients who undergo partial splenectomy&#46; This evaluation of splenectomised patients 26 years after the introduction of this procedure in the IHI reinforces its efficacy and safety&#44; showing no significant increase in the risk of overwhelming infections&#46; The procedure is also likely to protect from thromboembolic events in the long term&#44; and from other complications described after total splenectomy&#46; A clinical trial must be conducted with a larger number of patients to compare the results of these 2 splenectomy methods and thoroughly investigate the finding of liver sequestration following the procedure&#46; The identification of markers of platelet activation&#44; coagulation&#44; and intravascular haemolysis could be important to elucidate some of the results obtained in our study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2013-06-21"
    "fechaAceptado" => "2013-11-08"
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            0 => "Sickle cell disease"
            1 => "Partial splenectomy"
            2 => "Total splenectomy"
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          "palabras" => array:3 [
            0 => "Drepanocitosis"
            1 => "Esplenectom&#237;a parcial"
            2 => "Esplenectom&#237;a total"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Total splenectomy in sickle cell disease is related to a high risk of fulminant sepsis and increased incidence of other events&#44; which have not been reported in patients with partial splenectomy&#46; In this study we examined the patients with sickle cell disease and partial splenectomy and compared the clinical and laboratory results with non-splenectomised patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We studied 54 patients with sickle cell disease who underwent partial splenectomy in childhood from 1986 until 2011 at the Institute of Hematology and Immunology&#46; They were compared with 54 non-splenectomised patients selected by random sampling with similar characteristics&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Partial splenectomy was performed at a mean age of 4&#46;1 years&#44; with a higher frequency in homozygous haemoglobin S &#40;70&#46;4&#37;&#41;&#44; and the most common cause was recurrent splenic sequestration crisis&#46; The most common postoperative complications were fever of unknown origin &#40;14&#46;8&#37;&#41; and acute chest syndrome &#40;11&#46;1&#37;&#41;&#46; After splenectomy there was a significant increase in leukocytes&#44; neutrophils&#44; and platelets&#44; the latter two parameters remained significantly elevated when compared with non-splenectomised patients&#46; There was no difference in the incidence of clinical events&#44; except hepatic sequestration&#44; which was more common in splenectomised patients&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Partial splenectomy was a safe procedure in patients with sickle cell disease&#46; There were no differences in the clinical picture in children splenectomised and non-splenectomised except the greater frequency of hepatic sequestration crisis in the first group&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La esplenectom&#237;a total en la drepanocitosis se relaciona con riesgo de infecciones sobreagudas y con aumento de la incidencia de otros eventos&#44; lo que no se ha comunicado en pacientes con esplenectom&#237;a parcial&#46; En este estudio se caracteriz&#243; a los pacientes con drepanocitosis y esplenectom&#237;a parcial&#44; y se compar&#243; el comportamiento cl&#237;nico y de laboratorio con los pacientes no esplenectomizados&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materials y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se estudi&#243; a 54 pacientes con drepanocitosis sometidos a esplenectom&#237;a parcial durante la edad pedi&#225;trica&#44; desde 1986 hasta el a&#241;o 2011&#44; en el Instituto de Hematolog&#237;a e Inmunolog&#237;a&#46; Se compararon con 54 pacientes no esplenectomizados seleccionados por muestreo aleatorio con caracter&#237;sticas similares&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La esplenectom&#237;a parcial se realiz&#243; a una edad media de 4&#44;1 a&#241;os&#44; con una frecuencia mayor en la anaemia drepanoc&#237;tica &#40;70&#44;4&#37;&#41; y su causa m&#225;s com&#250;n fue la crisis de secuestro espl&#233;nico recurrente&#46; Las complicaciones posoperatorias m&#225;s frecuentes fueron&#58; fiebre de origen desconocido &#40;14&#44;8&#37;&#41; y s&#237;ndrome tor&#225;cico agudo &#40;11&#44;1&#37;&#41;&#46; Despu&#233;s de la esplenectom&#237;a&#44; aumentaron significativamente los leucocitos&#44; neutr&#243;filos y plaquetas&#59; estos 2 &#250;ltimos par&#225;metros se mantuvieron elevados de manera significativa cuando se compararon con los pacientes no esplenectomizados&#46; No hubo diferencias en la incidencia de los eventos cl&#237;nicos&#44; excepto el secuestro hep&#225;tico&#44; que fue m&#225;s frecuente en los esplenectomizados&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La esplenectom&#237;a parcial constituy&#243; un proceder seguro en los pacientes con drepanocitosis&#46; No hubo diferencias en el cuadro cl&#237;nico entre los ni&#241;os esplenectomizados y los no esplenectomizados&#44; salvo la mayor frecuencia de crisis de secuestro hep&#225;tico en los primeros&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guti&#233;rrez D&#237;az AI&#44; Svarch E&#44; Arencibia N&#250;&#241;ez A&#44; Sabournin Ferrier V&#44; Mach&#237;n Garc&#237;a S&#44; Menendez Veit&#237;a A&#44; et al&#46; Esplenectom&#237;a parcial en pacientes con drepanocitosis&#46; An Pediatr &#40;Barc&#41;&#46; 2015&#59;82&#58;228&#8211;234&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Haematological variables before and after splenectomy&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Splenectomised <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Non-splenectomised <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Phenotype SS&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38 &#40;70&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43 &#40;79&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;266&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male sex&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;687&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age &#40;years&#41;&#44; mean &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;1 &#40;1&#46;7&#8211;33&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;924&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Duration of follow-up &#40;years&#41;&#44; mean &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;2 &#40;0&#46;3&#8211;32&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;756&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Splenectomised</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Non-splenectomised</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Haemoglobin &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;43&#8211;8&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;73&#8211;8&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;342&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Reticulocytes &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;7&#8211;15&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;7&#8211;14&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Leukocytes &#40;&#215;10<span class="elsevierStyleSup">9</span>&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;8&#8211;11&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;0&#8211;11&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;060&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Neutrophils &#40;&#215;10<span class="elsevierStyleSup">9</span>&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;1&#8211;5&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;5&#8211;5&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;026&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Platelets &#40;&#215;10<span class="elsevierStyleSup">9</span>&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">386&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">366&#46;4&#8211;405&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">342&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">323&#46;9&#8211;360&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab802074.png"
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Haematological variables in splenectomised and non-splenectomised patients&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">VOPC&#58; vaso-occlusive pain crisis&#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"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical event &#40;&#215;100 patients&#47;year&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Splenectomised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Non-splenectomised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Acute chest syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;560&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;559&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">VOPC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;821&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hospital admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;246&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Transfusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;377&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab802072.png"
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            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Comparison of clinical events in the splenectomised patient group vs the non-splenectomised patient group&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "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=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical event&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Splenectomised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Non-splenectomised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hepatic sequestration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;25&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#40;9&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;041&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hepatic crisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;16&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;332&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Priapism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;11&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;355&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Thrombosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;3&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;558&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab802073.png"
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        ]
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Comparison of other clinical events in the patients under study&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">CBF&#58; cerebral blood flow&#59; SD&#58; standard deviation&#59; TRJV&#58; tricuspid regurgitant jet velocity&#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"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Splenectomised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Non-splenectomised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">TRJV<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2&#46;5<span class="elsevierStyleHsp" style=""></span>m&#47;s&#44;<span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total 227 &#40;31&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total 174 &#40;23&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">TRJV &#40;m&#47;s&#41;&#44;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">CBF<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>170<span class="elsevierStyleHsp" style=""></span>cm&#47;s&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total 348 &#40;23&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total 343 &#40;8&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">CBF &#40;cm&#47;s&#41;&#44;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">137&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>35&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">122&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>35&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab802071.png"
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Comparison of other clinical variables in the patients under study&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:28 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sickle-cell disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46;C&#46; Rees"
                            1 => "T&#46;N&#46; Williams"
                            2 => "M&#46;T&#46; Gladwin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(10)61029-X"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2011"
                        "volumen" => "376"
                        "paginaInicial" => "2018"
                        "paginaFinal" => "2031"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21131035"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Partial splenectomy in sickle cell syndromes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Nouri"
                            1 => "M&#46; Montalembert"
                            2 => "Y&#46; Revillon"
                            3 => "R&#46; Girot"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dis Child"
                        "fecha" => "1991"
                        "volumen" => "66"
                        "paginaInicial" => "1070"
                        "paginaFinal" => "1072"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1929516"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Splenic complications of sickle cell anemia and the role of splenectomy&#46; ISRN Hematology &#91;Internet&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46;H&#46; Al-Salem"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:2 [
                        "fecha" => "2011"
                        "paginaInicial" => "7 p"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
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Original Article
Partial splenectomy in sickle cell disease
Esplenectomía parcial en pacientes con drepanocitosis
A.I. Gutiérrez Díaza,
Corresponding author
adysg74@yahoo.es

Corresponding author.
, E. Svarcha, A. Arencibia Núñeza, V. Sabournin Ferriera, S. Machín Garcíaa, A. Menendez Veitíaa, L. Ramón Rodrigueza, J. Serrano Mirabala, T. García Peraltaa, L.G. López Martinb
a Instituto de Hematología e Inmunología, La Habana, Cuba
b Servicio de cirugía, Hospital Pediátrico Docente William Soler, La Habana, Cuba
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sickle cell disease is a multisystemic condition&#44; and splenic complications are among its most prominent manifestations&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Spleen enlargement is common in the first decade of life&#44; but vascular occlusive events and recurrent splenic infarctions lead to autosplenectomy&#46; However&#44; splenomegaly persists in some patients to later ages&#44; and other patients require splenectomy for various reasons&#44; such as recurrent splenic sequestration crises &#40;SSCs&#41;&#44; hypersplenism&#44; massive splenic infarction&#44; and splenic abscess&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The most common indication for splenectomy in sickle cell disease is SSC&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Total splenectomy is the classical treatment for SSC in children older than 4 years&#44; but the procedure often carries a high risk of fulminant septicaemia&#44; which may be fatal&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The risk is greater in younger children&#44; in whom the preferred approach is a transfusion regime until at least 2 years of age&#46; Aiming to avoid or reduce the adverse effects of total splenectomy&#44; the Institute of Haematology and Inmunology &#40;IHI&#41; started to perform partial splenectomies in 1986&#44; with excellent results&#46; The remaining spleen remains functional&#44; at least partially&#44; for a period of time that has yet to be determined&#44; and SSCs do not recur&#44; which supports the indication of partial splenectomy in patients with sickle cell disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#8211;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">For a long time&#44; total splenectomy was only associated to increased risk of overwhelming infections&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Recent publications have described an increased incidence of vaso-occlusive pain crises &#40;VOPCs&#41;&#44; acute chess syndrome &#40;ACS&#41;&#44; and stroke following total splenectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Today it is also associated with thrombotic complications&#44; such as deep-venous thrombosis&#44; especially portal venous thrombosis&#44; and with pulmonary hypertension &#40;PHT&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a> These and other complications have not been reported in patients with partial splenectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#8211;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Due to all the risks currently known to be associated with total splenectomy&#44; there is a growing interest in partial splenectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The aim of this study was to characterise the clinical and laboratory features of patients with sickle cell disease that had undergone partial splenectomy&#44; and to compare them with those of non-splenectomised patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We performed an observational&#44; retrospective&#44; comparative study in patients with sickle cell disease who received ongoing care at the haemoglobinopathies clinic of the IHI between September 2010 and December 2011&#46; The source population consisted of patients with sickle cell disease receiving care at the paediatric and adult departments of the IHI&#46; From it we selected a group of patients aged 1&#8211;18 years who had undergone a partial splenectomy&#46; We excluded patients who did not want to participate or whose parents or guardians did not give consent&#44; and patients whose records did not include any postoperative clinical data&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study included 54 splenectomised patients&#44; so we selected a comparative group of non-splenectomised patients with similar characteristics &#40;age&#44; sex&#44; type of haemoglobinopathy&#41; subject to the same exclusion criteria&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We reviewed the medical histories to collect demographic data and postoperative clinical data pertaining to sickle cell disease&#46; We calculated the annual mean counts of haemoglobin&#44; reticulocytes&#44; leukocytes&#44; neutrophils&#44; and platelets&#44; for both before and 6 months after splenectomy&#46; We recorded baseline values for patients &#40;when they had been without transfusions for at least 3 months and without acute clinical events for at least 1 month&#41;&#46; In the group of non-splenectomised patients&#44; the data were collected starting at age 4&#46;1 years&#44; which is the mean age at which patients were splenectomised&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We analysed cerebral blood flow &#40;CBF&#41; measured by transcranial Doppler ultrasound&#44; and values of tricuspid regurgitant jet velocity &#40;TRJV&#41; obtained by echocardiography after splenectomy&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We expressed qualitative variables as absolute and relative frequencies&#46; We analysed them using the Chi-squared test&#44; and calculated the odds ratio &#40;OR&#41;&#46; Quantitative variables were summarised as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#44; and analysed using ANOVA for comparing means and Student&#39;s t test for matched pairs&#46; We determined the frequency of events per 100 patients per year&#46; The data were analysed with the statistical software SPSS version 12&#46;0&#46;0&#46; We set the confidence level at 95&#37; and the statistical significance at <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>&#46;05 for all the tests performed&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Ethical considerations</span><p id="par0050" class="elsevierStylePara elsevierViewall">We adhered to the ethical principles of the Helsinki Declaration&#46; We asked all parents&#44; guardians&#44; and patients for informed consent&#46; The study protocol was reviewed and approved by the ethics committee and the scientific board of our hospital&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">The study included a total of 54 patients that underwent partial splenectomy&#44; and 54 non-splenectomised patients&#46; Patients with sickle cell anaemia accounted for 70&#46;4&#37; of the splenectomies&#44; HbS&#946;<span class="elsevierStyleSup">0</span> thalassaemia patients for 20&#46;4&#37;&#44; and HbS&#946;<span class="elsevierStyleSup">&#43;</span> thalassaemia patients for 9&#46;3&#37;&#46; Male patients predominated in both groups&#44; accounting for 66&#46;7&#37; of splenectomised patients&#46; The mean age was 15&#46;1 years &#40;range&#44; 1&#46;7&#8211;33&#46;7 years&#41; and the duration of follow-up in the clinic was 9&#46;6 years for the group of splenectomised patients&#46; The groups were comparable &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The indication for performing a partial splenectomy was hypersplenism in 7&#46;4&#37; of the operated patients&#44; at a mean age of 7&#46;4 years &#40;range&#44; 2&#46;6&#8211;15&#46;4 years&#41;&#44; and recurrent splenic sequestration in the remaining patients &#40;92&#46;6&#37;&#41; at a mean age of 3&#46;8 years &#40;range&#44; 0&#46;9&#8211;13&#46;8 years&#41;&#46; The mean age at the time of splenectomy for all patients was 4&#46;1 years&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Postoperative complications developed in 33&#46;4&#37; of the splenectomised patients&#46; The most frequent complications were fever without source &#40;14&#46;8&#37;&#41; and ACS &#40;11&#46;1&#37;&#41;&#46; Sepsis developed in 3&#46;7&#37; of these patients&#44; surgical site infections in 1&#46;9&#37;&#44; and subphrenic abscess in another 1&#46;9&#37;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the comparison of haematological variables in patients before and after splenectomy&#46; Following surgery&#44; there was a significant increase &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; in leukocytes &#40;from 9&#46;9 to 11&#46;4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#41;&#44; platelets &#40;from 270&#46;1 to 386&#46;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#41;&#44; and neutrophils &#40;from 4&#46;1 to 5&#46;4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#41;&#46; Although the increase was not significant&#44; mean haemoglobin rose from 7&#46;55 to 7&#46;86<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;227&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The comparison of haematological variables between splenectomised and non-splenectomised patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; showed a significant increase in the neutrophil count &#40;5&#46;4 vs 4&#46;8<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;026&#41; and platelet count &#40;386&#46;1 vs 342&#46;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;002&#41; of operated patients&#46; In splenectomised patients&#44; the mean leucocyte count was 11&#46;4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#44; and in non-splenectomised patients it was 10&#46;6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;060&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the number of events per 100 patients per year&#44; 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The increase was not statistically significant&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> compares the frequency of other clinical events&#46; Hepatic sequestration crises occurred in 14 &#40;25&#46;9&#37;&#41; of the splenectomised patients&#44; a finding that was statistically significant &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;041&#41;&#46; This clinical event did not appear in either group before age 4&#46;1 years&#46; The differences in the rest of the analysed clinical events were not significant&#46; The mean incidence of SSC was 4&#46;0 before splenectomy&#44; and this clinical event did not appear after surgery&#46; In non-splenectomised patients&#44; the mean incidence of SSC was 0&#46;54 before age 4&#46;1 years&#44; and 0&#46;11 after&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> shows that the prevalence of a TRJV of 2&#46;5<span class="elsevierStyleHsp" style=""></span>m&#47;s or greater was of 31&#46;8&#37; in splenectomised patients compared to 23&#46;5&#37; in non-splenectomised patients &#40;OR<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>1&#46;51&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;56&#41;&#46; The mean TRJV was 2&#46;16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;43<span class="elsevierStyleHsp" style=""></span>m&#47;s in splenectomised patients&#44; and 1&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;46<span class="elsevierStyleHsp" style=""></span>m&#47;s in non-splenectomised patients&#46; The CBF velocity measured by transcranial Doppler ultrasound was 170<span class="elsevierStyleHsp" style=""></span>cm&#47;s or greater in 23&#46;5&#37; of splenectomised patients&#44; while these velocities were only seen in 8&#46;8&#37; of non-splenectomised patients &#40;OR<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>3&#46;18&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;09&#41;&#46; The mean CBF velocity was 137&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>35&#46;4<span class="elsevierStyleHsp" style=""></span>cm&#47;s in splenectomised patients&#44; and 122&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>35&#46;7<span class="elsevierStyleHsp" style=""></span>cm&#47;s in non-splenectomised patients&#46; These results approached statistical significance &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;09&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">At the IHI&#44; partial splenectomy is a safe and effective procedure for children with sickle cell disease who require it&#44; thanks to advances in immunoprophylaxis&#44; accrued knowledge in the management of the disease&#44; and the experience gained in partial splenectomy since 1986&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Most splenectomised patients had sickle cell anaemia&#44; the most prevalent type of sickle cell disease in Cuba&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> which is also the most severe form of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Following in frequency were patients with HbS&#946;<span class="elsevierStyleSup">0</span> thalassaemia&#44; which is the third most prevalent haemoglobinopathy in Cuba&#44; but has a severe clinical course that cannot be discerned from that of sickle cell anaemia&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> so that its manifestations are analysed in combination with those of sickle cell anaemia in most studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The mean duration of follow-up after splenectomy was 9&#46;6 years&#44; which was similar to follow-up in the non-splenectomy group&#44; a fact that allowed us to make a broader characterisation of the disease&#46; Duration of follow-up is shorter in international studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;8&#44;9&#44;16</span></a> We only found 1 study with comparative groups of non-splenectomised patients and patients who had undergone total splenectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The average age at which splenectomy is performed for SSC ranges from 2&#46;7 to 7&#46;6 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;8&#44;18</span></a> In our study&#44; the mean age was 3&#46;8 years&#44; with a slightly broader range of 0&#46;9&#8211;13&#46;8 years&#46; At the IHI&#44; partial splenectomy is performed after 2 years of age in patients who have had 2 splenic sequestration events&#46; Before this age&#44; patients are treated with a hypertransfusion regime&#46; Partial splenectomy was performed in 13 &#40;24&#37;&#41; patients before 2 years of age&#44; a figure that corresponded to approximately half the cases reported by Kalpatthi et al&#46; for this age group&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The indications for the procedure were very severe&#44; life-threatening recurrent SSCs that occurred despite the hypertransfusion regime&#44; and early alloimmunisation in 1 patient&#46; The latter child underwent splenectomy before age 1 year because he became alloimmunised against 3 erythrocyte antibodies &#40;C&#44; E&#44; Fya&#41; in the first month of the hypertransfusion regime&#46; These antigens are more frequent in the Caucasian patients that constitute the majority of donors in Cuba&#44; which is the main reason why patients with sickle cell disease become alloimmunised&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The 13-year-old patient who underwent partial splenectomy had sickle cell anaemia and was being treated with hydroxyurea&#46; Ninety-four percent of patients with sickle cell anaemia progress to functional autosplenectomy by around 5 years of age&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> but patients treated with hydroxyurea may maintain splenic function for longer&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;21</span></a> This could account for the recurrent SSCs in older patients&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The mean age of the children who underwent splenectomy for hypersplenism was 7&#46;4 years&#46; Three of the 4 patients splenectomised for hypersplenism were patients with HbS&#946; thalassaemia&#44; 2 of them with S&#946;<span class="elsevierStyleSup">0</span> thalassaemia&#46; Splenectomy in patients with hypersplenism resulted in reduced need for transfusions and removed the intra-abdominal pressure exerted by the enlarged spleen&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Around 20&#8211;30&#37; of patients with sickle cell disease develop postoperative complications&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> One of the most frequent immediate complications is ACS&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;8&#44;16&#44;22</span></a> In our study&#44; 33&#46;4&#37; of patients developed postoperative complications&#44; and had a favourable outcome&#46; The most frequent complications were fever of unknown source and ACS&#46; Laparoscopic total splenectomy is associated to a shorter hospital stay and the same postoperative complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;18&#44;23</span></a> Recently&#44; there have been reports of laparoscopic partial splenectomy procedures in patients with hereditary spherocytosis&#44; sickle cell disease&#44; and focal splenic tumours&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;24&#44;25</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Our study found a significant increase in platelets and leukocytes after splenectomy&#46; These results are consistent with the findings of other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;8&#44;9</span></a> Patients with recurrent SSCs may have a degree of hypersplenism&#44; which would account for the increase in platelet and leucocyte counts following splenectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Kalpatthi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> did not find significant changes in the haemoglobin and reticulocyte counts from before and after total splenectomy&#46; The results of our study were consistent with this&#46; A study of patients with sickle cell anaemia and recurrent SSC found a significant increase in the neutrophil count after total splenectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In our study&#44; the results of patients with partial splenectomy were similar&#46; The studies on partial splenectomy that we reviewed did not compare haematological variables of splenectomised an non-splenectomised patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;26</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Recent studies describe a higher incidence of VOPC&#44; ACS&#44; and stroke in patients with total splenectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9&#44;17</span></a> Other authors suggest that this difference may be due to increased blood viscosity due to leukocytosis and thrombocytosis&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Yet others believe it is part of the natural course of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However&#44; Wright et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> compared a group of patients with total splenectomy with a non-splenectomised control group&#44; and found a significantly higher incidence of VOPC and ACS in splenectomised patients&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In this study&#44; clinical events in splenectomised patients were not significantly different from those in the comparison group&#44; although we found a slightly higher average number of infections&#44; VOPC&#44; hospital admissions&#44; and transfusions in the former group&#46; However&#44; there was a significant increase in hepatic sequestration crisis &#40;HSC&#41; after partial splenectomy compared to non-splenectomised patients&#46; It is likely that SSC and HSC have the same pathophysiological basis&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Patients with sickle cell disease are in a chronic prothrombotic state that is exacerbated during acute vaso-occlusive events&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Current evidence shows that patients with haemolytic anaemias are at higher risk for thromboembolic complications&#44; especially after total splenectomy&#46; The higher frequency of these complications may be due to the greater number of circulating microparticles and of erythrocytes that expose phosphatidylserine on their surface&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;27</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The clinical manifestations of thrombophilia in sickle cell disease include venous thromboembolism&#44; in situ pulmonary thrombosis&#44; and stroke&#44; all of which are more frequent in patients who have undergone total splenectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> However&#44; we did not find significant differences between the 2 groups&#44; either in thrombotic events or in stroke&#44; which suggests that the splenic remnant may protect against these complications&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In the context of our study&#44; partial splenectomy was not associated to the development of leg ulcers and priapism&#44; vascular complications that are frequent in sickle cell disease and correlate to the severity of haemolysis&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> but we must take into account that leg ulcers are rare in children&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Total splenectomy is a risk factor for the development of PHT&#46; In patients with beta thalassaemia&#44; PHT has a high prevalence of up to 70&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The prevalence in sickle cell disease is about 30&#37; when echocardiography is used as a diagnostic method&#44; determining the TRJV to estimate the pulmonary artery pressure&#44; but it has not been studied in splenectomised patients&#46; A TRJV of 2&#46;5<span class="elsevierStyleHsp" style=""></span>m&#47;s or greater is associated with a poor prognosis in several studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;19</span></a> In our study&#44; a TRJV of 2&#46;5<span class="elsevierStyleHsp" style=""></span>m&#47;s or greater was 1&#46;51 times more prevalent in splenectomised patients&#44; although this difference was not significant&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">One of the predictors of stroke is cerebral blood flow velocity measured by transcranial Doppler ultrasonography&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> We found no difference in the incidence of stroke between the two groups of patients in our study&#59; however&#44; alterations in cerebral blood flow velocity were 3&#46;18 times more frequent in splenectomised patients than in non-splenectomised patients&#44; a difference that neared statistical significance&#46; These results are consistent with what has been reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The greater frequency of cerebral flow abnormalities in splenectomised patients could be a risk factor for stroke&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">This study allowed us to increase our knowledge of the clinical and haematological changes that occur in patients who undergo partial splenectomy&#46; This evaluation of splenectomised patients 26 years after the introduction of this procedure in the IHI reinforces its efficacy and safety&#44; showing no significant increase in the risk of overwhelming infections&#46; The procedure is also likely to protect from thromboembolic events in the long term&#44; and from other complications described after total splenectomy&#46; A clinical trial must be conducted with a larger number of patients to compare the results of these 2 splenectomy methods and thoroughly investigate the finding of liver sequestration following the procedure&#46; The identification of markers of platelet activation&#44; coagulation&#44; and intravascular haemolysis could be important to elucidate some of the results obtained in our study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            0 => "Drepanocitosis"
            1 => "Esplenectom&#237;a parcial"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Total splenectomy in sickle cell disease is related to a high risk of fulminant sepsis and increased incidence of other events&#44; which have not been reported in patients with partial splenectomy&#46; In this study we examined the patients with sickle cell disease and partial splenectomy and compared the clinical and laboratory results with non-splenectomised patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We studied 54 patients with sickle cell disease who underwent partial splenectomy in childhood from 1986 until 2011 at the Institute of Hematology and Immunology&#46; They were compared with 54 non-splenectomised patients selected by random sampling with similar characteristics&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Partial splenectomy was performed at a mean age of 4&#46;1 years&#44; with a higher frequency in homozygous haemoglobin S &#40;70&#46;4&#37;&#41;&#44; and the most common cause was recurrent splenic sequestration crisis&#46; The most common postoperative complications were fever of unknown origin &#40;14&#46;8&#37;&#41; and acute chest syndrome &#40;11&#46;1&#37;&#41;&#46; After splenectomy there was a significant increase in leukocytes&#44; neutrophils&#44; and platelets&#44; the latter two parameters remained significantly elevated when compared with non-splenectomised patients&#46; There was no difference in the incidence of clinical events&#44; except hepatic sequestration&#44; which was more common in splenectomised patients&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Partial splenectomy was a safe procedure in patients with sickle cell disease&#46; There were no differences in the clinical picture in children splenectomised and non-splenectomised except the greater frequency of hepatic sequestration crisis in the first group&#46;</p></span>"
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            "titulo" => "Introduction"
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            "titulo" => "Materials and methods"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La esplenectom&#237;a total en la drepanocitosis se relaciona con riesgo de infecciones sobreagudas y con aumento de la incidencia de otros eventos&#44; lo que no se ha comunicado en pacientes con esplenectom&#237;a parcial&#46; En este estudio se caracteriz&#243; a los pacientes con drepanocitosis y esplenectom&#237;a parcial&#44; y se compar&#243; el comportamiento cl&#237;nico y de laboratorio con los pacientes no esplenectomizados&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materials y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se estudi&#243; a 54 pacientes con drepanocitosis sometidos a esplenectom&#237;a parcial durante la edad pedi&#225;trica&#44; desde 1986 hasta el a&#241;o 2011&#44; en el Instituto de Hematolog&#237;a e Inmunolog&#237;a&#46; Se compararon con 54 pacientes no esplenectomizados seleccionados por muestreo aleatorio con caracter&#237;sticas similares&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La esplenectom&#237;a parcial se realiz&#243; a una edad media de 4&#44;1 a&#241;os&#44; con una frecuencia mayor en la anaemia drepanoc&#237;tica &#40;70&#44;4&#37;&#41; y su causa m&#225;s com&#250;n fue la crisis de secuestro espl&#233;nico recurrente&#46; Las complicaciones posoperatorias m&#225;s frecuentes fueron&#58; fiebre de origen desconocido &#40;14&#44;8&#37;&#41; y s&#237;ndrome tor&#225;cico agudo &#40;11&#44;1&#37;&#41;&#46; Despu&#233;s de la esplenectom&#237;a&#44; aumentaron significativamente los leucocitos&#44; neutr&#243;filos y plaquetas&#59; estos 2 &#250;ltimos par&#225;metros se mantuvieron elevados de manera significativa cuando se compararon con los pacientes no esplenectomizados&#46; No hubo diferencias en la incidencia de los eventos cl&#237;nicos&#44; excepto el secuestro hep&#225;tico&#44; que fue m&#225;s frecuente en los esplenectomizados&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La esplenectom&#237;a parcial constituy&#243; un proceder seguro en los pacientes con drepanocitosis&#46; No hubo diferencias en el cuadro cl&#237;nico entre los ni&#241;os esplenectomizados y los no esplenectomizados&#44; salvo la mayor frecuencia de crisis de secuestro hep&#225;tico en los primeros&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guti&#233;rrez D&#237;az AI&#44; Svarch E&#44; Arencibia N&#250;&#241;ez A&#44; Sabournin Ferrier V&#44; Mach&#237;n Garc&#237;a S&#44; Menendez Veit&#237;a A&#44; et al&#46; Esplenectom&#237;a parcial en pacientes con drepanocitosis&#46; An Pediatr &#40;Barc&#41;&#46; 2015&#59;82&#58;228&#8211;234&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Haematological variables before and after splenectomy&#46;</p>"
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      1 => array:7 [
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        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Splenectomised <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Non-splenectomised <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Phenotype SS&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38 &#40;70&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43 &#40;79&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;266&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male sex&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;66&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;687&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age &#40;years&#41;&#44; mean &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;1 &#40;1&#46;7&#8211;33&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;3 &#40;4&#46;3&#8211;36&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;924&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Duration of follow-up &#40;years&#41;&#44; mean &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;6 &#40;0&#46;3&#8211;25&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;2 &#40;0&#46;3&#8211;32&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;756&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "tabla" => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Splenectomised</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Non-splenectomised</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Haemoglobin &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;43&#8211;8&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;73&#8211;8&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;342&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Reticulocytes &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;7&#8211;15&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;7&#8211;14&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Leukocytes &#40;&#215;10<span class="elsevierStyleSup">9</span>&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;8&#8211;11&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;0&#8211;11&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;060&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Neutrophils &#40;&#215;10<span class="elsevierStyleSup">9</span>&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;1&#8211;5&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;5&#8211;5&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;026&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Platelets &#40;&#215;10<span class="elsevierStyleSup">9</span>&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">386&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">366&#46;4&#8211;405&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">342&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">323&#46;9&#8211;360&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Haematological variables in splenectomised and non-splenectomised patients&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">VOPC&#58; vaso-occlusive pain crisis&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical event &#40;&#215;100 patients&#47;year&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Splenectomised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Non-splenectomised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Acute chest syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;560&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;559&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">VOPC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;821&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hospital admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;246&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Transfusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;377&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical event&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Splenectomised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Non-splenectomised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hepatic sequestration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;25&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#40;9&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;041&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hepatic crisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;16&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;332&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Priapism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;11&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;355&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Thrombosis&nbsp;\t\t\t\t\t\t\n
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Idiomas
Anales de Pediatría (English Edition)
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?