Case and Research Letters
Treatment of the Mucocutaneous Manifestations of Hereditary Hemorrhagic Telangiectasia Using the Nd:YAG Laser (1064nm)
Tratamiento de las manifestaciones mucocutáneas en la telangiectasia hemorrágica hereditaria con láser pulsado Nd:YAG (1.064nm)
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B) Resultado tras una sesión de tratamiento en el borde y dorso izquierdos de la mucosa lingual. Compárese con el lado que no ha sido tratado. C) Resultado tras 2 sesiones de tratamiento de toda la mucosa lingual. D) Resultado final tras 3 sesiones de tratamiento. Gran aclaramiento de la lesiones.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. de Quintana-Sancho, J.L. Díaz-Ramón, E. Acebo-Mariñas, A. Cánovas-Fernández" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "de Quintana-Sancho" ] 1 => array:2 [ "nombre" => "J.L." "apellidos" => "Díaz-Ramón" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Acebo-Mariñas" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Cánovas-Fernández" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1578219016000159" "doi" => "10.1016/j.adengl.2016.01.013" "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/S1578219016000159?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731015003944?idApp=UINPBA000044" "url" => "/00017310/0000010700000002/v2_201603080122/S0001731015003944/v2_201603080122/es/main.assets" ] ] "itemAnterior" => array:19 [ "pii" => "S1578219015003534" "issn" => "15782190" "doi" => "10.1016/j.adengl.2015.12.003" "estado" => "S300" "fechaPublicacion" => "2016-03-01" "aid" => "1256" "copyright" => "AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2016;107:169-70" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 827 "formatos" => array:3 [ "EPUB" => 34 "HTML" => 488 "PDF" => 305 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Erythema Multiforme Associated With Phenytoin and Cranial Radiation Therapy (EMPACT Syndrome) in a Patient With Lung Cancer" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "169" "paginaFinal" => "170" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome Erythema Multiforme associated with Phenytoin And Cranial radiation Therapy (EMPACT) en paciente con neoplasia pulmonar" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 800 "Ancho" => 800 "Tamanyo" => 156855 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous-edematous plaques with areas of skin detachment and erosive semimucosal lesions on the lips.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Vilas-Sueiro, I. Vázquez-Osorio, J.M. Suárez-Peñaranda, D. Sánchez-Aguilar" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Vilas-Sueiro" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Vázquez-Osorio" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Suárez-Peñaranda" ] 3 => array:2 [ "nombre" => "D." "apellidos" => "Sánchez-Aguilar" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731015003932" "doi" => "10.1016/j.ad.2015.06.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731015003932?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219015003534?idApp=UINPBA000044" "url" => "/15782190/0000010700000002/v2_201703220318/S1578219015003534/v2_201703220318/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Treatment of the Mucocutaneous Manifestations of Hereditary Hemorrhagic Telangiectasia Using the Nd:YAG Laser (1064<span class="elsevierStyleHsp" style=""></span>nm)" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "171" "paginaFinal" => "173" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. de Quintana-Sancho, J.L. Díaz-Ramón, E. Acebo-Mariñas, A. Cánovas-Fernández" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "de Quintana-Sancho" "email" => array:1 [ 0 => "adriandeq@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.L." "apellidos" => "Díaz-Ramón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Acebo-Mariñas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Cánovas-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Cruces, Baracaldo, Vizcaya, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Cruces, Baracaldo, Vizcaya, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de las manifestaciones mucocutáneas en la telangiectasia hemorrágica hereditaria con láser pulsado Nd:YAG (1.064<span class="elsevierStyleHsp" style=""></span>nm)" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 463 "Ancho" => 1057 "Tamanyo" => 116947 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Mucocutaneous telangiectases on the nose, cheeks, and lips of patient #2. B, Excellent clearance of lesions after 4 treatment sessions.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Osler-Weber-Rendu disease, otherwise known as hereditary hemorrhagic telangiectasia (HHT), is characterized by the presence of epistaxis and multiple mucocutaneous telangiectases in association with arteriovenous malformations affecting different organs, including the lungs, the gastrointestinal system, and the central nervous system. The prevalence of the disease varies, with rates ranging from 1 case per 5000 people to 1 case per 8000 people. HHT is an autosomal dominant disorder with high penetrance. Most patients have mutations in the endoglin (<span class="elsevierStyleItalic">ENG</span>) or activin receptor-like kinase I (<span class="elsevierStyleItalic">ACVRL1</span>) genes. <span class="elsevierStyleItalic">ENG</span> and <span class="elsevierStyleItalic">ACVRL1</span> mutations affect the signaling of transforming growth factor β, which is a cytokine involved in angiogenesis.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> A mutation in the <span class="elsevierStyleItalic">SMAD4</span> gene has also been described in a small proportion of patients with HHT, who may have associated juvenile polyposis syndrome.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">HHT is diagnosed on the basis of the Curaçao criteria, which include epistaxis (spontaneous or recurrent), multiple mucocutaneous telangiectases in characteristic locations, visceral lesions (gastrointestinal, pulmonary, hepatic, or cerebral arteriovenous malformations), and a diagnosis of HHT in at least 1 first-degree relative. The diagnosis is considered definitive if 3 or more of these criteria are met, possible if 2 criteria are met, and unlikely if fewer than 2 criteria are met.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Mucocutaneous telangiectases are the most evident sign of HHT. Apart from being cosmetically bothersome, these lesions can cause bleeding and have a considerable impact on quality of life in 27% of cases. Skin lesions are uncommon in childhood and tend to appear after the second decade. Although numerous studies have described the use of lasers to treat various types of facial telangiectases (e.g., idiopathic telangiectases, Civatte poikiloderma, rosacea), little has been published on their use in the treatment of telangiectases in patients with HHT. In this study, we describe our experience with the use of a long-pulse Nd:YAG laser to treat mucocutaneous manifestations of HHT.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Nine patients referred to the dermatology department at Hospital Universitario Cruces in Baracaldo, Spain, received long-pulse Nd:YAG laser treatment for HHT-related telangiectases between January 2012 and December 2014. The patients’ characteristics are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. All the lesions were treated with a Cynergy long-pulse Nd:YAG laser (Cynosure), which emits monochromatic light with a wavelength of 1064<span class="elsevierStyleHsp" style=""></span>nm. A skin cooling system with air flow levels of between 5 and 7 (Cryo 5, Zimmer Medizinsysteme GmbH) was used to protect the skin during treatment.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Sedation with nitrous oxide (Entonox) was necessary in just 2 cases. In our experience, lesions located on the finger pulp are particularly painful. In 1 patient with lesions affecting the tongue, we used a topical anesthetic spray (lidocaine, Xilonibsa) to numb the oral mucosa. The rest of the patients tolerated the treatment well without local anesthesia.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The treatment achieved considerable clearance of both skin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and mucosal (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) lesions in few sessions (mean, 2.2 sessions; range, 1-7 sessions), and there were no notable adverse effects such as scarring, persistent purpura, or dyschromia. Patient #2 experienced posttreatment bleeding that was resolved by compression. The best outcomes were observed with the following laser settings: a 5-mm spot size, a pulse time of 15 and 25<span class="elsevierStyleHsp" style=""></span>ms, and a mean fluence of 127.5<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span> (range, 115-145<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>). As a precaution, in patients with lesions of the posterior tongue, we treated just one side of the tongue per session. The patients experienced postoperative swelling, but there were no signs of dyspnea or dysphagia. As postoperative treatment, we recommended an antiseptic mouthwash and oral prednisone at a dose of 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg for 3 days to reduce swelling. The worst outcome was observed for patient #8, who was treated with a spot size of 3<span class="elsevierStyleHsp" style=""></span>mm and a fluence that was probably insufficient. We suggested undergoing a second session, but the patient decided not to, as the treatment had been for cosmetic purposes only.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Numerous types of lasers have been described in the treatment of mucocutaneous telangiectases in HHT, namely, a pulsed KTP laser (532<span class="elsevierStyleHsp" style=""></span>nm), an Nd:YAG laser (1064<span class="elsevierStyleHsp" style=""></span>nm), a diode laser (810<span class="elsevierStyleHsp" style=""></span>nm), and a pulsed dye laser.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4–7</span></a> There have also been reports of cases treated with argon and carbon dioxide lasers, although these offer little specificity for the wavelengths of hemoglobin.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In the case of pulsed dye lasers, more sessions have been found to be necessary to achieve clearance of telangiectases in patients with HHT than in those without. This is possibly because of the aberrant structure of blood vessels or abnormal vascular remodeling in HHT.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Fernández-Jorge et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> described the combined use of an intense pulsed light laser and a long-pulse Nd:YAG laser to treat telangiectases in 3 patients with HHT. All of the patients experienced good cosmetic outcomes and a reduced frequency of bleeding episodes.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Nd:YAG laser therapy is an effective treatment for mucocutaneous telangiectases in patients with HHT. In our series, excellent results were obtained with few sessions and no remarkable adverse effects. However, due to the natural course of the disease, patients should be followed and new lesions retreated as necessary.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as: de Quintana-Sancho A, Díaz-Ramón JL, Acebo-Mariñas E, Cánovas-Fernández A. Tratamiento de las manifestaciones mucocutáneas en la telangiectasia hemorrágica hereditaria con láser pulsado Nd:YAG (1.064<span class="elsevierStyleHsp" style=""></span>nm). Actas Dermosifiliogr. 2016;107:171–173.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 463 "Ancho" => 1057 "Tamanyo" => 116947 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Mucocutaneous telangiectases on the nose, cheeks, and lips of patient #2. B, Excellent clearance of lesions after 4 treatment sessions.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1250 "Ancho" => 1250 "Tamanyo" => 379913 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Multiple telangiectases, with episodes of spontaneous bleeding, on the tongue of patient #9. B, Result of 1 treatment session, in which the left dorsum and lateral surface of the tongue were treated. Note the difference with respect to the right, untreated side. C, Result after 2 sessions, with treatment of the whole surface of the tongue. D, Result after 3 treatment sessions. Note the excellent clearance achieved.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "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">Patient \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">Sex \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">Age, y \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">Location of Lesions \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">Gene Involved \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of Laser Sessions; Settings<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \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">Improvement (% Clearance<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>) \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">Level of Satisfaction<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \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">Level of Pain<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Face<br>Fingers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">ACVRL1</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7; Nd:YAG (5-20-115) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Face<br>Tongue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">ACVRL1</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4; Nd:YAG (5-15-135) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Face<br>Fingers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">ACVRL1</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1; Nd:YAG (5-25-145) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Face \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ACVRL1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1; Nd:YAG (5-20-120) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Man \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Face<br>Tongue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">ACVRL1</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1; Nd:YAG (5-15-125) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Man \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Face<br>Tongue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">ACVRL1</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1; Nd:YAG (5-20-125) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Face<br>Fingers<br>Tongue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">ENG</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1; Nd:YAG (5-20-120) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Man \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Face \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">ENG</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1; Nd:YAG (3-15-100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tongue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">ACVRL1</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3; Nd:YAG (5-20-135) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1375524.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Nd:YAG laser: spot (mm)-pulse (ms)-fluence (J/cm<span class="elsevierStyleSup">2</span>).</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Scale of 1 to 4, where 1 indicates 0%-25% clearance; 2, 26%-50% clearance, 3, 51%-75% clearance; and 4, 76%-100% clearance.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Scale of 0 to 10, where 0 indicates complete dissatisfaction and 10 indicates complete satisfaction.</p>" ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Scale of 0 to 10, where 0 indicates no pain and 10 indicates unbearable pain.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical Characteristics of Patients, Laser Settings, and Treatment Results.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hereditary hemorrhagic telangiectasia: Genetics and molecular diagnostics in a new era" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 1 | 4 | 5 |
| 2024 Octubre | 104 | 40 | 144 |
| 2024 Septiembre | 96 | 25 | 121 |
| 2024 Agosto | 133 | 56 | 189 |
| 2024 Julio | 122 | 34 | 156 |
| 2024 Junio | 128 | 46 | 174 |
| 2024 Mayo | 100 | 42 | 142 |
| 2024 Abril | 89 | 30 | 119 |
| 2024 Marzo | 100 | 30 | 130 |
| 2024 Febrero | 88 | 42 | 130 |
| 2024 Enero | 81 | 39 | 120 |
| 2023 Diciembre | 101 | 26 | 127 |
| 2023 Noviembre | 122 | 22 | 144 |
| 2023 Octubre | 127 | 34 | 161 |
| 2023 Septiembre | 98 | 33 | 131 |
| 2023 Agosto | 86 | 23 | 109 |
| 2023 Julio | 90 | 32 | 122 |
| 2023 Junio | 99 | 26 | 125 |
| 2023 Mayo | 143 | 26 | 169 |
| 2023 Abril | 139 | 29 | 168 |
| 2023 Marzo | 120 | 32 | 152 |
| 2023 Febrero | 95 | 21 | 116 |
| 2023 Enero | 70 | 33 | 103 |
| 2022 Diciembre | 89 | 36 | 125 |
| 2022 Noviembre | 32 | 16 | 48 |
| 2022 Octubre | 35 | 22 | 57 |
| 2022 Septiembre | 30 | 29 | 59 |
| 2022 Agosto | 32 | 29 | 61 |
| 2022 Julio | 34 | 28 | 62 |
| 2022 Junio | 22 | 16 | 38 |
| 2022 Mayo | 47 | 36 | 83 |
| 2022 Abril | 66 | 40 | 106 |
| 2022 Marzo | 63 | 47 | 110 |
| 2022 Febrero | 57 | 35 | 92 |
| 2022 Enero | 79 | 51 | 130 |
| 2021 Diciembre | 58 | 50 | 108 |
| 2021 Noviembre | 49 | 48 | 97 |
| 2021 Octubre | 68 | 56 | 124 |
| 2021 Septiembre | 57 | 40 | 97 |
| 2021 Agosto | 64 | 31 | 95 |
| 2021 Julio | 55 | 34 | 89 |
| 2021 Junio | 43 | 37 | 80 |
| 2021 Mayo | 47 | 35 | 82 |
| 2021 Abril | 77 | 57 | 134 |
| 2021 Marzo | 52 | 18 | 70 |
| 2021 Febrero | 52 | 28 | 80 |
| 2021 Enero | 40 | 23 | 63 |
| 2020 Diciembre | 35 | 11 | 46 |
| 2020 Noviembre | 30 | 25 | 55 |
| 2020 Octubre | 37 | 17 | 54 |
| 2020 Septiembre | 34 | 8 | 42 |
| 2020 Agosto | 23 | 22 | 45 |
| 2020 Julio | 18 | 16 | 34 |
| 2020 Junio | 37 | 35 | 72 |
| 2020 Mayo | 16 | 17 | 33 |
| 2020 Abril | 30 | 22 | 52 |
| 2020 Marzo | 23 | 13 | 36 |
| 2020 Febrero | 9 | 0 | 9 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Octubre | 1 | 0 | 1 |
| 2019 Septiembre | 7 | 0 | 7 |
| 2019 Junio | 2 | 0 | 2 |
| 2019 Mayo | 2 | 1 | 3 |
| 2019 Abril | 0 | 4 | 4 |
| 2019 Marzo | 2 | 6 | 8 |
| 2019 Febrero | 1 | 0 | 1 |
| 2019 Enero | 1 | 0 | 1 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 7 | 0 | 7 |
| 2018 Marzo | 1 | 1 | 2 |
| 2018 Febrero | 30 | 5 | 35 |
| 2018 Enero | 34 | 5 | 39 |
| 2017 Diciembre | 29 | 6 | 35 |
| 2017 Noviembre | 34 | 4 | 38 |
| 2017 Octubre | 23 | 10 | 33 |
| 2017 Septiembre | 22 | 4 | 26 |
| 2017 Agosto | 30 | 8 | 38 |
| 2017 Julio | 25 | 9 | 34 |
| 2017 Junio | 27 | 5 | 32 |
| 2017 Mayo | 22 | 8 | 30 |
| 2017 Abril | 25 | 7 | 32 |
| 2017 Marzo | 9 | 6 | 15 |
| 2017 Febrero | 64 | 5 | 69 |
| 2017 Enero | 19 | 6 | 25 |
| 2016 Diciembre | 30 | 10 | 40 |
| 2016 Noviembre | 18 | 8 | 26 |
| 2016 Octubre | 12 | 18 | 30 |
| 2016 Julio | 2 | 5 | 7 |
| 2016 Junio | 0 | 1 | 1 |
| 2016 Mayo | 0 | 1 | 1 |
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