Case and Research Letters
Fukushima: What a Dermatologist Should Know
Fukushima: lo que el dermatólogo debe saber
Servicio de Dermatología, Hospital Clínico San Carlos, Madrid, Spain
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Fueyo-Casado, J. Pedraz-Muñoz" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Fueyo-Casado" "email" => array:1 [ 0 => "afueyo@aedv.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Pedraz-Muñoz" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital Clínico San Carlos, Madrid, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fukushima: lo que el dermatólogo debe saber" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Japan has suffered one of the worst earthquakes in the history of humanity (9 points on the Richter scale) followed by a devastating tsunami with waves over 20 meters high, and the country is now facing the consequences of the serious damage to some of its nuclear power plants, in particular Fukushima. The accident has sparked fear worldwide concerning the potential risks of nuclear radiation. I believe that it is of interest to explain some important concepts regarding radioactivity,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the real risks to human health and, as we are dermatologists, the cutaneous manifestations observed in cases of exposure to ionizing radiation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The core of a nuclear reactor contains over 60 radioactive contaminants, the products of uranium fission. The radioactive particles released in the course of the Fukushima nuclear emergency were mostly iodine 131 and cesium 137; radioactive iodine, which has a half-life of 8 days, is taken up by the thyroid gland, and cesium, with a half-life of 30 years, is deposited in the muscles. Plutonium leaks were also detected. In the Chernobyl accident, by contrast, due to the explosion of one of the nuclear reactors, large amounts of strontium 90 and some of the nuclear fuel (uranium) and its decay product (plutonium) were also released. These reaction products are much more dangerous to health and have a much longer half-life.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Radioactive substances emit ionizing radiation, that is, radiation that has enough energy to ionize matter by removing electrons that are bound to an atom. This process produces free radicals, which directly damage DNA and cell proteins and result in radiation-induced genomic instability.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Non-ionizing radiation (electromagnetic fields and electromagnetic radiation in the visible spectrum) does not have this effect.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Ionizing radiation also occurs at low levels in nature, and there are various types, as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">Alpha particles (2 protons and 2 neutrons)</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0030" class="elsevierStylePara elsevierViewall">Beta particles (an electron or a positron)</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall">Gamma rays (photons)</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0040" class="elsevierStylePara elsevierViewall">X-rays</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0045" class="elsevierStylePara elsevierViewall">Neutrons</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">The dose of ionizing radiation absorbed by matter is measured in grays (Gy). The effective dose absorbed by an organism is measured in sievert (Sv), a unit that takes into account both the type of ionizing radiation and the biological effects produced. In Spain, we are exposed to a dose of between 2.4 and 3 millisieverts (mSv) per year. (In Fukushima, levels thousands of times greater than the permitted threshold have been detected.) Exposure to an annual dose below 100 mSv is considered to be safe.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Some of the effects of ionizing radiation are stochastic or random rather than dose dependent and may occur after low-level exposure, although the probability of damage increases with the dose received. There are also dose-dependent deterministic effects. The physical repercussions of ionizing radiation depend on the individual's distance from the radiation source, the sensitivity of each type of tissue, the absorbed dose rate, and the radioactive materials involved.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Ionizing radiation has been classified as a confirmed carcinogen by the International Agency for Research on Cancer. It can cause every type of cancer except mesothelioma.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Exposure to a megadose, as in the case of a nuclear accident, can cause acute radiation syndrome (a 5000 mSv single dose would kill approximately half of the exposed population within 1 month).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–7</span></a> In such circumstances, four phases would be observed<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1.</span><p id="par0065" class="elsevierStylePara elsevierViewall">The prodromal phase: anorexia, apathy, nausea, vomiting, diarrhea, fever, tachycardia, and headache, occurring between 2 and 6 days after exposure.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">2.</span><p id="par0070" class="elsevierStylePara elsevierViewall">The latent phase: transient improvement lasting between several days and 1 month. The duration of the latent phase is inversely related to the dose received.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">3.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Manifest disease phase: intense immunosuppression and pancytopenia that may result in complete myelosuppression. Central nervous system involvement giving rise to headache, cognitive deficits, hyporeflexia, and stroke Gastrointestinal symptoms: diarrhea, abdominal pain, and gastrointestinal bleeding. Skin disease, which will be discussed below. Treatment requires individualized life support measures (fluids, antibiotics, platelets, granulopoietic cytokines, transfusions, hematopoietic cell transplantation), and the administration of potassium iodide at doses of 130<span class="elsevierStyleHsp" style=""></span>mg/d in adults.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,7</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">4.</span><p id="par0080" class="elsevierStylePara elsevierViewall">Death or recovery phase: survivors will require lifelong follow-up due to the long-term risk of carcinogenesis and to treat sequelae</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">Cutaneous radiation syndrome or radiation dermatitis is also seen following iatrogenic exposure.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–8</span></a> There are acute and chronic clinical manifestations. Acute radiation dermatitis is caused by high-energy radiation and develops after a latent period of 6 to 12 days following exposure and with cumulative doses of more than 7<span class="elsevierStyleHsp" style=""></span>Gy. Depending on severity, radiation dermatitis is classified as:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">1.</span><p id="par0090" class="elsevierStylePara elsevierViewall">First degree: erythema that resolves leaving diffuse or mottled hyperpigmentation. Exposure of 3<span class="elsevierStyleHsp" style=""></span>Gy or more produces transient alopecia and reduced sebaceous gland activity. These manifestations develop some 3 weeks after exposure and resolve between 4 and 12 weeks.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">2.</span><p id="par0095" class="elsevierStylePara elsevierViewall">Second degree: this develops after exposure to doses ranging from 8 to 10<span class="elsevierStyleHsp" style=""></span>Gy and takes the form of erythema, edema, and blistering. It is also associated with permanent loss of hair, sebaceous glands, sweat glands, and nails.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">3.</span><p id="par0100" class="elsevierStylePara elsevierViewall">Third degree: deep necrosis, slow-healing scabs and ulcers associated with sequelae, and an increased risk of squamous cell carcinoma.</p></li></ul></p><p id="par0105" class="elsevierStylePara elsevierViewall">Chronic radiation dermatitis occurs with doses above 12 to 15<span class="elsevierStyleHsp" style=""></span>Gy and develops after a latency period of 2 years. The clinical features include atrophic and sclerotic skin, loss of appendages, hyper- or hypopigmentation, and telangiectasia. The risk of ulcers and skin cancer is high (these form on precursor lesions called roentgen keratoses, which are similar to actinic keratoses).</p><p id="par0110" class="elsevierStylePara elsevierViewall">In both acute and chronic disease, involvement tends to be patchy since non-irradiated basal cells give rise to clones that generate patches of healthy skin, which are surrounded by diseased areas. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the main reactions of human skin to ionizing radiation and the threshold dose and time to occurrence of each reaction.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The treatment of acute radiation dermatitis is symptomatic and involves the application of emollients and topical corticosteroids. Indometacin and other nonsteroidal oral anti-inflammatory drugs may help to reduce pain and edema. Granulation tissue does not form in chronic radiation dermatitis, and treatment is limited to surgical debridement and skin grafting. Carcinomas and roentgen keratoses are treated in the conventional manner.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Dedication</span><p id="par0120" class="elsevierStylePara elsevierViewall">To all of those working every day to control the radiation leaks in Fukushima, Japan.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Dedication" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Fueyo-Casado A, Pedraz-Muñoz J. Fukusima: lo que el dermatólogo debe saber. Actas Dermosifiliogr.2011;102:631-644.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0125" class="elsevierStylePara elsevierViewall">When a leak is detected in a radioactive installation, measures must be taken to prevent contamination, such as those that were implemented following the Fukushima accident:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">1.</span><p id="par0130" class="elsevierStylePara elsevierViewall">Contact with the skin can be eliminated by thorough washing with detergent and disposal of clothes.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">2.</span><p id="par0135" class="elsevierStylePara elsevierViewall">Iodine is the only effective measure in the case of particle inhalation. The iodine saturates the thyroid gland, thereby preventing the uptake of radioactive iodine. However, this measure provides no protection against cesium or strontium uptake.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">3.</span><p id="par0140" class="elsevierStylePara elsevierViewall">A total exclusion zone with a radius of 20 to 30 kilometers around the source of radioactivity (irrespective of political boundaries) in which no civilians are permitted to remain is complemented by a second peripheral area in which people remain ready for evacuation and must stay inside their homes with the doors and windows tightly closed. The IAEA (International Atomic Energy Agency) monitors radiation levels at various distances from the source and orders the appropriate preventive measures.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">4.</span><p id="par0145" class="elsevierStylePara elsevierViewall">The nuclear fallout is deposited on the land and in the sea, where it is incorporated into the trophic chain, contaminating plants and animals. To reduce the risks the authorities may place a temporary ban on the sale of products originating in the affected area. Other countries may also impose bans or restrictions on imports from the affected areas. In any case, rigorous monitoring of radioactivity levels in agricultural and food products is essential.</p></li></ul></p>" "etiqueta" => "Appendix A" "titulo" => "Preventive Measures<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>" "identificador" => "sec0010" ] ] ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Effect \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Approximate Threshold Dose (Gray) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Time to Appearance \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Early transient erythema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2-24 h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Main erythematous reaction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 wks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Temporary hair loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 wks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Permanent hair loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 wks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dry desquamation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4-6 wks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moist desquamation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 wks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Secondary ulceration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">> 6 wks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Late erythema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8-10 wks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ischemic dermal necrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 wks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Skin atrophy (1st phase) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">> 52 wks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Telangiectasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">> 52 wks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dermal necrosis (late stage) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">> 15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">> 52 wks \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab181857.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Principal Effects of Ionizing Radiation on the Skin: Threshold Dose and Time to Appearance.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiobiology for the radiologist" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E.J. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 10 | 10 | 20 |
| 2024 Octubre | 85 | 44 | 129 |
| 2024 Septiembre | 106 | 23 | 129 |
| 2024 Agosto | 110 | 43 | 153 |
| 2024 Julio | 89 | 32 | 121 |
| 2024 Junio | 120 | 42 | 162 |
| 2024 Mayo | 84 | 29 | 113 |
| 2024 Abril | 55 | 44 | 99 |
| 2024 Marzo | 63 | 29 | 92 |
| 2024 Febrero | 70 | 30 | 100 |
| 2024 Enero | 51 | 31 | 82 |
| 2023 Diciembre | 55 | 18 | 73 |
| 2023 Noviembre | 58 | 31 | 89 |
| 2023 Octubre | 52 | 16 | 68 |
| 2023 Septiembre | 52 | 31 | 83 |
| 2023 Agosto | 27 | 16 | 43 |
| 2023 Julio | 38 | 31 | 69 |
| 2023 Junio | 30 | 22 | 52 |
| 2023 Mayo | 40 | 25 | 65 |
| 2023 Abril | 38 | 16 | 54 |
| 2023 Marzo | 52 | 27 | 79 |
| 2023 Febrero | 42 | 26 | 68 |
| 2023 Enero | 34 | 40 | 74 |
| 2022 Diciembre | 43 | 51 | 94 |
| 2022 Noviembre | 46 | 26 | 72 |
| 2022 Octubre | 29 | 25 | 54 |
| 2022 Septiembre | 18 | 34 | 52 |
| 2022 Agosto | 29 | 31 | 60 |
| 2022 Julio | 20 | 36 | 56 |
| 2022 Junio | 16 | 24 | 40 |
| 2022 Mayo | 39 | 32 | 71 |
| 2022 Abril | 44 | 41 | 85 |
| 2022 Marzo | 42 | 51 | 93 |
| 2022 Febrero | 27 | 23 | 50 |
| 2022 Enero | 36 | 30 | 66 |
| 2021 Diciembre | 38 | 40 | 78 |
| 2021 Noviembre | 40 | 41 | 81 |
| 2021 Octubre | 28 | 41 | 69 |
| 2021 Septiembre | 22 | 40 | 62 |
| 2021 Agosto | 29 | 37 | 66 |
| 2021 Julio | 17 | 36 | 53 |
| 2021 Junio | 23 | 49 | 72 |
| 2021 Mayo | 23 | 34 | 57 |
| 2021 Abril | 39 | 56 | 95 |
| 2021 Marzo | 59 | 12 | 71 |
| 2021 Febrero | 39 | 28 | 67 |
| 2021 Enero | 21 | 18 | 39 |
| 2020 Diciembre | 35 | 16 | 51 |
| 2020 Noviembre | 16 | 27 | 43 |
| 2020 Octubre | 22 | 14 | 36 |
| 2020 Septiembre | 21 | 9 | 30 |
| 2020 Agosto | 25 | 25 | 50 |
| 2020 Julio | 23 | 19 | 42 |
| 2020 Junio | 25 | 22 | 47 |
| 2020 Mayo | 26 | 14 | 40 |
| 2020 Abril | 26 | 17 | 43 |
| 2020 Marzo | 27 | 19 | 46 |
| 2020 Febrero | 2 | 0 | 2 |
| 2020 Enero | 0 | 1 | 1 |
| 2019 Diciembre | 4 | 2 | 6 |
| 2019 Octubre | 0 | 3 | 3 |
| 2019 Septiembre | 6 | 1 | 7 |
| 2019 Agosto | 0 | 1 | 1 |
| 2019 Julio | 0 | 3 | 3 |
| 2019 Junio | 0 | 20 | 20 |
| 2019 Mayo | 4 | 38 | 42 |
| 2019 Abril | 1 | 9 | 10 |
| 2019 Marzo | 0 | 14 | 14 |
| 2019 Febrero | 2 | 1 | 3 |
| 2019 Enero | 0 | 2 | 2 |
| 2018 Diciembre | 1 | 7 | 8 |
| 2018 Noviembre | 2 | 0 | 2 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 1 | 0 | 1 |
| 2018 Agosto | 0 | 2 | 2 |
| 2018 Abril | 0 | 2 | 2 |
| 2018 Marzo | 9 | 0 | 9 |
| 2018 Febrero | 23 | 3 | 26 |
| 2018 Enero | 35 | 7 | 42 |
| 2017 Diciembre | 27 | 6 | 33 |
| 2017 Noviembre | 28 | 5 | 33 |
| 2017 Octubre | 31 | 4 | 35 |
| 2017 Septiembre | 19 | 9 | 28 |
| 2017 Agosto | 41 | 7 | 48 |
| 2017 Julio | 36 | 6 | 42 |
| 2017 Junio | 47 | 11 | 58 |
| 2017 Mayo | 32 | 15 | 47 |
| 2017 Abril | 34 | 5 | 39 |
| 2017 Marzo | 32 | 36 | 68 |
| 2017 Febrero | 30 | 8 | 38 |
| 2017 Enero | 14 | 9 | 23 |
| 2016 Diciembre | 51 | 8 | 59 |
| 2016 Noviembre | 35 | 2 | 37 |
| 2016 Octubre | 38 | 9 | 47 |
| 2016 Septiembre | 41 | 4 | 45 |
| 2016 Agosto | 48 | 8 | 56 |
| 2016 Julio | 35 | 2 | 37 |
| 2016 Junio | 13 | 14 | 27 |
| 2016 Mayo | 13 | 0 | 13 |
| 2016 Abril | 4 | 5 | 9 |
| 2016 Marzo | 6 | 0 | 6 |
| 2016 Febrero | 9 | 3 | 12 |
| 2016 Enero | 3 | 0 | 3 |
| 2015 Diciembre | 7 | 2 | 9 |
| 2015 Noviembre | 10 | 2 | 12 |
| 2015 Octubre | 9 | 2 | 11 |
| 2015 Septiembre | 12 | 1 | 13 |
| 2015 Agosto | 15 | 3 | 18 |
| 2015 Julio | 36 | 4 | 40 |
| 2015 Junio | 46 | 12 | 58 |
| 2015 Mayo | 77 | 17 | 94 |
| 2015 Abril | 44 | 10 | 54 |
| 2015 Marzo | 48 | 8 | 56 |
| 2015 Febrero | 31 | 9 | 40 |
| 2015 Enero | 36 | 4 | 40 |
| 2014 Diciembre | 56 | 6 | 62 |
| 2014 Noviembre | 30 | 11 | 41 |
| 2014 Octubre | 49 | 21 | 70 |
| 2014 Septiembre | 35 | 12 | 47 |
| 2014 Agosto | 41 | 13 | 54 |
| 2014 Julio | 49 | 20 | 69 |
| 2014 Junio | 56 | 11 | 67 |
| 2014 Mayo | 76 | 13 | 89 |
| 2014 Abril | 60 | 14 | 74 |
| 2014 Marzo | 73 | 12 | 85 |
| 2014 Febrero | 33 | 11 | 44 |
| 2014 Enero | 57 | 13 | 70 |
| 2013 Diciembre | 73 | 3 | 76 |
| 2013 Noviembre | 43 | 15 | 58 |
| 2013 Octubre | 50 | 8 | 58 |
| 2013 Septiembre | 12 | 5 | 17 |
| 2013 Agosto | 10 | 3 | 13 |
| 2013 Julio | 16 | 7 | 23 |
| 2013 Junio | 15 | 10 | 25 |
| 2013 Mayo | 22 | 11 | 33 |
| 2013 Abril | 12 | 8 | 20 |
| 2013 Marzo | 15 | 4 | 19 |
| 2013 Febrero | 23 | 6 | 29 |
| 2013 Enero | 14 | 2 | 16 |
| 2012 Diciembre | 9 | 3 | 12 |
| 2012 Noviembre | 1 | 1 | 2 |
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