Scientific Letter
SARS-CoV-2 pandemic impact in asthmatic exacerbations emergency visits in Spain
Impacto de la pandemia SARS-COV-2 en las exacerbaciones asmáticas en urgencias pediátricas en España
Esther Pérez Suáreza,
, Natalia Paniagua Calzónb, Svetlana Pavlovic Nesicc, Gemma Claret Terueld, Esther Lera Carvalloe, en representación del Grupo de trabajo respiratorio Sociedad Española de Urgencias Pediátricas (SEUP) 1
Corresponding author
a Servicio de Urgencias Pediátricas, Hospital Niño Jesús, Madrid, Spain
b Servicio de Urgencias Pediátricas, Hospital de Cruces, Barakaldo, Bizkaia, Spain
c Servicio de Pediatría, Hospital de Gran Canaria, Complejo Hospitalario Materno Infantil de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
d Servicio de Urgencias Pediátricas, Hospital San Joan de Deu, Esplugues de Llobregat, Barcelona, Spain
e Servicio de Urgencias Pediátricas, Hospital de Val d`Hebron, Barcelona, Spain
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Se muestran en barras el número de exacerbaciones asmáticas atendidas en cada temporada. En la tabla se refleja el porcentaje del número de urgencias en las temporadas de la pandemia respecto a la temporada prepandemia. La línea gris refleja la evolución del SARS-CoV-2 cada mes. En colores se señalan las épocas en las distintas fases de medidas de aislamiento y cuarentena.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Esther Pérez Suárez, Natalia Paniagua Calzón, Svetlana Pavlovic Nesic, Gemma Claret Teruel, Esther Lera Carvallo" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Esther" "apellidos" => "Pérez Suárez" ] 1 => array:2 [ "nombre" => "Natalia" "apellidos" => "Paniagua Calzón" ] 2 => array:2 [ "nombre" => "Svetlana" "apellidos" => "Pavlovic Nesic" ] 3 => array:2 [ "nombre" => "Gemma" "apellidos" => "Claret Teruel" ] 4 => array:2 [ "nombre" => "Esther" "apellidos" => "Lera Carvallo" ] 5 => array:1 [ "colaborador" => "en representación del Grupo de trabajo respiratorio Sociedad Española de Urgencias Pediátricas (SEUP)" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341287923000716" "doi" => "10.1016/j.anpede.2023.01.015" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287923000716?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403323000115?idApp=UINPBA00005H" "url" => "/16954033/0000009800000005/v1_202305032020/S1695403323000115/v1_202305032020/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2341287923000807" "issn" => "23412879" "doi" => "10.1016/j.anpede.2023.02.020" "estado" => "S300" "fechaPublicacion" => "2023-05-01" "aid" => "3427" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "An Pediatr (Barc). 2023;98:387-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Impact of molecular biology in children with ALK+ inflammatory myofibroblastic tumour. 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respiratorio Sociedad Española de Urgencias Pediátricas (SEUP)" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Servicio de Urgencias Pediátricas, Hospital Niño Jesús, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Urgencias Pediátricas, Hospital de Cruces, Barakaldo, Bizkaia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital de Gran Canaria, Complejo Hospitalario Materno Infantil de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Urgencias Pediátricas, Hospital San Joan de Deu, Esplugues de Llobregat, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Urgencias Pediátricas, Hospital de Val d`Hebron, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Impacto de la pandemia SARS-COV-2 en las exacerbaciones asmáticas en urgencias pediátricas en España" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 4186 "Ancho" => 2500 "Tamanyo" => 847845 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Visits due to asthma exacerbation in each of the 3 seasons and in each hospital. Chart reflecting the number of visits due to asthma exacerbation managed in the given month. The first chart presents the total visits due to asthma exacerbations to all participating hospitals. Subsections 1 through 8 present the data broken down by hospital.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Children with asthma were considered a risk group on the advent of the SARS-CoV-2 pandemic<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>; after the initial alarm, several studies in different countries evinced a decreased incidence of exacerbations during the pandemic.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> Data on this subject have not been published in Spain.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The Working Group on Respiratory Disease of the Sociedad Española de Urgencias Pediátricas (Spanish Society of Paediatric Emergency Medicine) proposed performing a retrospective multicentre study. It consisted in analysing the monthly visits to paediatric emergency departments (PEDs) due to asthma exacerbations, defined as diagnostic code J45.909 or J45.22 of International Classification of Diseases 10th Revision (ICD-10), the proportions of cases resulting in admission to the ward and to the paediatric intensive care unit (PICU) in the first 2 years of the pandemic, and the association of exacerbations to the cumulative incidence of infection by SARS-CoV-2 at 14 days and the different quarantine periods.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Eight hospitals agreed to participate in the study. The analysis included a total of 1 096 624 visits to participating PEDs, with 50 337 care episodes for exacerbations, 6631 admissions to the ward and 498 admissions to the PICU. Visits to the PED due to asthma exacerbations decreased by more than half in the first year of the pandemic (47.72% of the number of prepandemic visits) and grew back to a similar frequency in the second year (91.82% of the number of prepandemic visits). Although the total volume of PED visits for any reason also decreased, the decrease in the volume of visits due to exacerbations was greater. The percentage of PED visits due to exacerbations decreased from 4.73% before the pandemic to 4.09% in the first year of the pandemic (4.85% in year 2). The monthly pattern of asthma exacerbations and their association with different waves of the pandemic were very similar across participating hospitals (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The mean annual proportion of exacerbations leading to admission did not increase significantly: 12.23% (standard deviation [DS], 8.39%) before the pandemic; 14.00% (SD, 10.56%) in the first year of the pandemic and 13.73% (SD, 15.73%) in the second year. There was also no increase in the proportion of PICU admission: 1.00% (SD, 0.51%) before the pandemic; 0.95% (SD, 0.21%) in the first year and 1.07% (SD, 0.64%) in the second year. The risk of hospital admission and of PICU admission due to asthma exacerbation did not increase with the SARS-CoV-2 pandemic either (OR 0.88 [CI, 0.79–1.24] and OR 0.97 [CI, 0.86–1.33], respectively).</p><p id="par0025" class="elsevierStylePara elsevierViewall">When we assessed the association between exacerbations (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) and successive pandemic waves, we found a decrease in their incidence in the first (March 2020), third (November 2020) and fourth (January 2021) waves. During the second wave, which took place during the step-down of precautions in September 2020, there was a peak in asthma exacerbations similar to the one observed before the pandemic in every hospital except those located in islands (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The fifth and sixth waves, which took place after most restrictions had been lifted (August 2021; January 2022), were preceded by an increase in exacerbations in children and a decrease that coincided with the peak of SARS-CoV-2 cases. The decrease in exacerbations during the first wave has been described extensively,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a> but the peak in exacerbations that coincided with the second wave observed in most hospitals in our case series, with the exception of those in islands, does not seem to have occurred in other countries.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The only meta-analysis in the literature<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> mentions as possible causes of the decrease in exacerbations during the pandemic the reduced exposure to respiratory viruses, the decrease in air pollution due to movement restrictions and the decreased exposure to allergens due to the use of masks. Some of these measures were analysed. Strict home confinement and restrictions to movement had a protective effect (OR, 0.27 [CI, 0.23−0.79] and OR, 0.65 [CI, 0.42−0.83]). The risk did not increase with the return to the classrooms (OR, 0.97; CI, 0.54–1.27) or with lifting the requirement to wear masks out of doors (OR 1.09; CI, 0.76–1.44). Differences between autonomous communities within Spain in the rest of applied measures precluded an analysis of their overall impact.</p><p id="par0035" class="elsevierStylePara elsevierViewall">This is the first study on the impact of SARS-CoV-2 on visits to PEDs due to asthma exacerbations, and it was conducted in a large sample of patients managed in 8 hospitals in 6 autonomous communities. The main limitations are its retrospective design, which does not allow the establishment of causal relationships, the lack of a demographic analysis and the fact that not every region in Spain was represented, which limits the extrapolation of the findings and the conclusions on the association of the factors.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, SARS-CoV-2 does not seem to have increased the frequency of exacerbations in children with asthma or related hospital or PICU admissions. The isolation measures introduced to control SARS-CoV-2 may have decreased exacerbations in children. One year later, the figures were once again similar to those before the pandemic. Some of the measures implemented during the pandemic could be contemplated for prevention of asthma exacerbations in children, although further research is required to determine the specific benefits of each of the measures while taking into account their psychosocial impact.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Annex 1. Working Group on Respiratory Disease of the Sociedad Española de Urgencias Pediátricas (SEUP (SEUP)</span><p id="par0045" class="elsevierStylePara elsevierViewall">Alonso Montejo, María del Mar. Hospital Universitario Virgen del Rocío*, Seville. Bustamante Hernández, Sandra. Hospital Universitari Mútua Terrassa, Terrassa, Barcelona. Claret Teruel, Gemma. Hospital Sant Joan de Déu*, Barcelona. González Díaz, Carlos. Hospital Universitario Basurto, Bilbao. Khodayar Pardo, Parisá. Hospital Clínico Universitario de Valencia, Valencia. Lera Carvallo, Esther. Hospital Universitario Vall d´Hebron*, Barcelona. Martínez Álvarez, Ana. Hospital Clínico Universitario Virgen de la Arrixaca, Murcia. Ovelar Zubiaga, Nerea. Hospital Universitario Donostia*,San Sebastian. Paniagua Calzón, Natalia. Hospital Universitario Cruces*, Bizkaia. Pavlovic Nesic, Svetlana. Hospital Universitario Materno Infantil de Las Palmas*, Las Palmas de Gran Canarias. Pérez Aragón, Ana. Hospital Universitario Virgen de las Nieves, Granada. Pérez García, Cristina. Hospital Universitario Santa Lucía de Cartagena*, Murcia. Pérez Suárez, Esther. Hospital Infantil Universitario Niño Jesús*, Madrid. Pons Morales, Sara Hospital Universitario Doctor Peset, Valencia. Soriano Arola, Marta. Hospital Universitari Son Espases*, Majorca.</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">*Hospitals that contributed data to the study</span>.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Annex 1. Working Group on Respiratory Disease of the Sociedad Española de Urgencias Pediátricas (SEUP (SEUP)" ] 1 => array:2 [ "identificador" => "xack665719" "titulo" => "Acknowledgments" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Previous meeting: partial results of this study were presented as a brief communication at the XXVI Meeting of the Sociedad Española de Urgencias de Pediatría; August 16, 2022; Pamplona, Spain.</p>" ] 1 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">All members of the Respiratory Task Force Spanish Society of Pediatric Emergencies (SEUP) presents in Annex 1.</p>" "identificador" => "fn0005" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 4186 "Ancho" => 2500 "Tamanyo" => 847845 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Visits due to asthma exacerbation in each of the 3 seasons and in each hospital. Chart reflecting the number of visits due to asthma exacerbation managed in the given month. The first chart presents the total visits due to asthma exacerbations to all participating hospitals. Subsections 1 through 8 present the data broken down by hospital.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2014 "Ancho" => 3341 "Tamanyo" => 633548 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Percentage of visits due to asthma exacerbations relative to the same month of the year before the pandemic. The bars show the number of asthma exacerbations managed each season. The table reflects the percentage of the number of emergency visits in the pandemic seasons compared to the prepandemic period. The grey line represents the trend in SARS-CoV-2 cases each month. The shadings correspond to the different phases of the quarantine and isolation measures.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The unexpected risks of COVID-19 on asthma control in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "N.M. Oreskovic" 1 => "T.B. Kinane" 2 => "E. Aryee" 3 => "K.A. Kuhlthau" 4 => "J.M. Perrin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaip.2020.05.027" "Revista" => array:7 [ "tituloSerie" => "J Allergy Clin Immunol Pract." "fecha" => "2020" "volumen" => "8" "numero" => "8" "paginaInicial" => "2489" "paginaFinal" => "2491" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32497662" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asthma and the risk of SARS-CoV-2 infection among children and adolescents" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Rao" 1 => "J.H. Hurst" 2 => "C. Zhao" 3 => "B.A. Goldstein" 4 => "L. Thomas" 5 => "J.E. Lang" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Pediatrics." "fecha" => "2022" "volumen" => "1" "paginaInicial" => "149" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The impact of lockdown on pediatric ED visits and hospital admissions during the COVID19 pandemic: a multicenter analysis and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.D. Kruizinga" 1 => "D. Peeters" 2 => "M. van Veen" 3 => "M. van Houten" 4 => "J. Wieringa" 5 => "J.G. Noordzij" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00431-021-04015-0" "Revista" => array:7 [ "tituloSerie" => "Eur J Pediatr" "fecha" => "2021" "volumen" => "180" "numero" => "7" "paginaInicial" => "2271" "paginaFinal" => "2279" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33723971" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric emergency care in New York City during the COVID-19 pandemic shutdown and reopening periods" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T. Liang" 1 => "H.S. Chamdawala" 2 => "E.T. Tay" 3 => "J. Chao" 4 => "M. Waseem" 5 => "H. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ajem.2022.03.049" "Revista" => array:6 [ "tituloSerie" => "Am J Emerg Med." "fecha" => "2022" "volumen" => "56" "paginaInicial" => "137" "paginaFinal" => "144" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/35397354" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric asthma exacerbations during the COVID-19 pandemic: absence of the typical fall seasonal spike in Washington, DC" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W.J. Sheehan" 1 => "S.J. Patel" 2 => "R.H.F. Margolis" 3 => "E.R. Fox" 4 => "D.Q. Shelef" 5 => "N. Kachroo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Allergy Clin Immunol Pract." "fecha" => "2021" "volumen" => "56" "paginaInicial" => "980" "paginaFinal" => "982" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric asthma control during the COVID-19 pandemic: a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Z. Yang" 1 => "X. Wang" 2 => "X.G. Wan" 3 => "M.L. Wang" 4 => "Z.H. Qiu" 5 => "J.L. Chen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ppul.25736" "Revista" => array:7 [ "tituloSerie" => "Pediatr Pulmonol." "fecha" => "2022" "volumen" => "57" "numero" => "1" "paginaInicial" => "20" "paginaFinal" => "25" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34672436" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack665719" "titulo" => "Acknowledgments" "texto" => "<p id="par0055" class="elsevierStylePara elsevierViewall">We thank Dr María del Mar Alonso Montejo, Dr Marta Soriano Arola, Dr Amaia Cámara Otegui and Dr Cristina Pérez García for their invaluable collaboration in the study.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000009800000005/v1_202305080100/S2341287923000716/v1_202305080100/en/main.assets" "Apartado" => array:4 [ "identificador" => "38181" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000009800000005/v1_202305080100/S2341287923000716/v1_202305080100/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287923000716?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 16 | 9 | 25 |
| 2024 October | 64 | 42 | 106 |
| 2024 September | 81 | 40 | 121 |
| 2024 August | 86 | 65 | 151 |
| 2024 July | 79 | 33 | 112 |
| 2024 June | 66 | 23 | 89 |
| 2024 May | 149 | 43 | 192 |
| 2024 April | 83 | 29 | 112 |
| 2024 March | 137 | 37 | 174 |
| 2024 February | 78 | 72 | 150 |
| 2024 January | 134 | 41 | 175 |
| 2023 December | 213 | 31 | 244 |
| 2023 November | 64 | 43 | 107 |
| 2023 October | 34 | 36 | 70 |
| 2023 September | 37 | 37 | 74 |
| 2023 August | 40 | 19 | 59 |
| 2023 July | 42 | 41 | 83 |
| 2023 June | 42 | 26 | 68 |
| 2023 May | 94 | 35 | 129 |
| 2023 April | 65 | 50 | 115 |
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