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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hemoptysis has a broad differential and optimal treatment depends on identifying cause and location of bleeding&#46; Even after an extensive work-up&#44; including chest radiography&#44; computed tomography&#44; bronchoscopy&#44; pulmonary angiography&#44; upper gastrointestinal endoscopy and an array of serological tests&#44; the cause of hemoptysis remains evasive in 20&#8211;30&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">An 18-year-old&#44; non-smoker and obese &#40;BMI &#8211; 38<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41; male presented with intermittent hemoptysis for six weeks&#44; 5 episodes with each episode had approximately 5&#8211;10<span class="elsevierStyleHsp" style=""></span>ml of blood&#46; The episodes were accompanied by cough&#44; no vomiting was reported&#46; He had no history of breathlessness&#44; wheeze&#44; chest pain&#44; palpitations&#44; bleeding from any other site or easy bruisability of gums or skin&#46; There were no complaints of joint pain&#44; Raynaud&#39;s phenomenon&#44; skin rash&#44; photosensitivity&#44; dryness of eyes or mouth&#46; There was no past history of similar complaints&#44; tuberculosis or contact with a tuberculosis patient&#46; There was no history of loss of weight or appetite or family history of similar complaints&#46; After multiple hospital visits and three admissions there was no resolution of his symptoms&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On examination&#44; there were no other lesions or rashes&#44; including telangiectasias&#44; petechiae&#44; or varicosities&#46; Rest of the examination was normal&#46; The list of investigational workup and their reports was normal &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Patient was then handed over a sputum container with instructions to wait in the hospital and inform immediately in case he had a hemoptysis episode&#46; The patient returned 25<span class="elsevierStyleHsp" style=""></span>min later with blood-tinged fluid in the container&#46; Also&#44; one of the finger ends had bleeding and rest other nail corners were normal and the patient said he put the finger in his mouth to stop bleeding&#46; The sample was sent for investigations like sputum for acid fast bacilli stain and culture&#46; Next day&#44; patient again showed five images of blood near the sink&#46; However&#44; each photograph had a different colour and type of sink&#46; On searching for hemoptysis images on the Internet&#44; we found pictures exactly similar to the patient&#39;s images&#46; The clinical course led us to a suspicion of factitious hemoptysis&#46; He was referred for a formal psychiatry evaluation where it was confirmed that the patient&#39;s grandfather had recently passed away&#44; whom he was greatly fond of&#46; He was now seeking the attention of his father by presenting himself as being sick&#46; Thus diagnosis of factitious hemoptysis&#44; due to factitious disorder &#40;FD&#41; &#40;previously known as M&#252;nchausen syndrome&#41; was made&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">We had another case of a 17-year-old female&#44; presented with a history of intermittent hemoptysis for four weeks&#44; 3 episodes with each episode had approximately 10&#8211;15<span class="elsevierStyleHsp" style=""></span>ml of blood&#46; The episodes were preceded by cough&#44; no vomiting was reported&#46; The patient had no history of breathlessness&#44; wheeze&#44; chest pain&#44; bleeding from any other site&#44; easy bruisability of the gums or skin or menstural complaints&#46; There were no symptoms suggestive of connective tissue disease&#46; There was no past history of similar complaints&#44; previous diagnosis of pulmonary tuberculosis or contact with anyone with tuberculosis&#46; There was no associated loss of weight or appetite or family history of similar complaints&#46; Patient had multiple hospital visits and investigations with no respite in symptoms&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">On examination&#44; there were few healed cut marks in the right forearm and the right index finger had loss of nail bed while the other nail beds were normal&#46; There were no other lesions&#44; rashes&#44; telangiectases&#44; petechiae&#44; or varicosities&#46; All investigations were normal &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The patient was given a sputum container and asked to immediately visit the hospital in case she has hemoptysis&#46; The patient returned the next day with blood-tinged fluid in the container Her vitals were normal and oral examination was normal&#46; The clinical course led us to suspicion of factitious hemoptysis&#46; The patient was referred for a psychiatry evaluation where she reported suicidal tendencies and a need to seek her father&#39;s attention&#46; Thus&#44; the diagnosis of FD &#40;Munchausen syndrome by proxy&#41; was established&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The current case series present two patients presenting with hemoptysis&#44; in whom the cause remained elusive despite extensive investigations&#46; Both the cases were successfully diagnosed and managed as factitious disorder &#40;FD&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">FD is characterised by falsified general medical or psychiatric symptoms imposed on self<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> which is rarely reported and often under-diagnosed&#46; Patients deliberately disguise&#44; simulate&#44; or cause symptoms of an illness and&#47;or injury to themselves&#46; FD imposed on self &#40;Munchausen syndrome&#41; is distinguished from FD imposed on another &#40;Munchausen syndrome by proxy&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> Early investigation of a possible FD can prevent patient self-harm as well as complications arising from unnecessary investigations and empirical treatments&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A systematic review of 455 cases<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> reported mean age of presentation as 34&#46;2 years with female preponderance &#40;66&#46;2&#37;&#41;&#46; Common presentations were simulated asthmatic episodes&#44; followed by hemoptysis&#44; acute respiratory failure &#40;acute respiratory distress&#44; inhalational pulmonary talcosis&#41;&#44; cystic fibrosis&#44; signs of collagen vascular disease&#44; and pneumothorax&#46; One patient was even reported to be difficult to wean from ventilator&#46; A broad keyword search of literature published in English between January 1&#44; 1950 and May 1&#44; 2019 was conducted in Pubmed database was searched using the terms&#44; factit&#42;&#44; munchausen&#42;&#44; artefacta&#42; and artefactua&#42;&#46; The records with terms &#8216;by proxy&#8217; or &#8216;imposed upon another&#8217; were not automatically filtered out in order to ensure inclusion of case series reporting both FD and FD imposed upon another&#46; The exclusion criteria were animal studies and clinical trials&#46; A total of 2081 records&#44; were retrieved for abstract review after removal of 436 duplicate&#46; A total of 29 studies were selected for inclusion after full-text review&#46; The bibliographies of eligible studies&#44; review papers and the results of a GoogleScholar search utilising terms identical to the keyword search&#46; These supplementary search processes yielded a further 5 eligible studies&#46; Thus a total of 34 studies were included for review &#40;Supplementary table&#41;&#46; The most common cause of this bleeding results from self-inflicted trauma in the oral cavity&#46; The other simulation method includes venesection and injecting their own blood in their mouth&#44; aspirated with a syringe&#44; either from a peripheral vein of their forearm or from a central venous catheter&#46; The use of mixture of iodine and soap solution&#44; as well as replacement of cherry juice in a sputum cup has been reported&#46; Sometimes&#44; the cause of bleeding remains obscure as patients left the hospital when they were confronted with suspicion&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Dimsdale et al&#46; reported FD as a long-term and persistent problem related to disease perception and identity&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> It may be associated with inexplicable and&#47;or unexpected symptoms&#46; The diagnosis of FD can be considered by meeting the following four criteria &#8211; a pattern of presentation to others as ill or impaired&#59; the behaviour is evident even in the absence of obvious external rewards&#59;&#44; the behaviour is not due to a delusional belief system or acute psychosis&#59; and the behaviour is not better accounted for by another mental disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> The cases described in this report presented with continuous hemoptysis and no obvious reward mechanism present&#46; Yue et al&#46; recently proposed the diagnostic algorithm for approach to a patient with unexplained hemoptysis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> The present report concludes to avoid over investigation and identification of psychiatric risk factors in this patient population with thorough history taking&#46;</p></span>"
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            "apendice" => "<p id="par0055" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0010"
          ]
        ]
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        "tipo" => "MULTIMEDIATABLA"
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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="\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" scope="col" style="border-bottom: 2px solid black">Investigation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Case 1 &#40;18 years&#47;male&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Case 2 &#40;17 years&#47;female&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></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  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Blood investigations</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Haemoglobin &#40;Hb&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Blood coagulate functions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Liver and Renal Function tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Radiology</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CXR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Computed Tomography of Chest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No abnormality reported&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No abnormality reported&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Computed Tomography of Sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ultrasonography of abdomen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Echocardiography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Angiogram&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Procedures</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Laryngoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Flexible bronchoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Esophagoduodenoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pulmonary Angiogram&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The investigation profile of both cases&#46;</p>"
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      "titulo" => "References"
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                0 => array:1 [
                  "referenciaCompleta" => "Davis JL&#44; Murray JF&#46; History and physical examination&#46; In&#58; Mason RJ&#44; Broaddus VC&#44; Martin T&#44; et al&#46; Murray and Nadel&#39;s textbook of respiratory medicine&#46; 6th ed&#46; Philadelphia&#44; PA&#58; Saunders Elsevier&#59; 2016&#58;263&#8211;76&#46;"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Diagnostic and Statistical Manual of Mental Disorders Fifth Edition &#40;DSM-5&#41;"
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                          "colaboracion" => "American Psychiatric Association"
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                        "editorialLocalizacion" => "Arlington&#44; VA"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Medical child abuse&#58; beyond munchausen syndrome by proxy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "T&#46;A&#46; Roesler"
                            1 => "C&#46; Jenny"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "Libro" => array:4 [
                        "edicion" => "1st ed&#46;"
                        "fecha" => "2009"
                        "editorial" => "American Academy of Pediatrics"
                        "editorialLocalizacion" => "Elk Grove Village"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Factitious disorder&#58; a systematic review of 455 cases in the professional literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "G&#46;P&#46; Yates"
                            1 => "M&#46;D&#46; Feldman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.genhosppsych.2016.05.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Gen Hosp Psychiatry"
                        "fecha" => "2016"
                        "volumen" => "41"
                        "paginaInicial" => "20"
                        "paginaFinal" => "28"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27302720"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0060"
              "etiqueta" => "5"
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