Editorial
COPD in Women: Future Challenges
Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, United States
Read
2552
Timeswas read the article
801
Total PDF
1751
Total HTML
Share statistics
array:23 [ "pii" => "S0300289622004859" "issn" => "03002896" "doi" => "10.1016/j.arbres.2022.06.008" "estado" => "S300" "fechaPublicacion" => "2023-01-01" "aid" => "3142" "copyright" => "SEPAR" "copyrightAnyo" => "2022" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Arch Bronconeumol. 2023;59:3-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S030028962200597X" "issn" => "03002896" "doi" => "10.1016/j.arbres.2022.10.009" "estado" => "S300" "fechaPublicacion" => "2023-01-01" "aid" => "3206" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Arch Bronconeumol. 2023;59:5-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:9 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Home High-Flow Oxygen Therapy Should Be Considered in Patients With COPD and Chronic Respiratory Failure" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "5" "paginaFinal" => "6" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Manel Luján" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Manel" "apellidos" => "Luján" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S030028962200597X?idApp=UINPBA00003Z" "url" => "/03002896/0000005900000001/v3_202311210639/S030028962200597X/v3_202311210639/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0300289622004835" "issn" => "03002896" "doi" => "10.1016/j.arbres.2022.06.006" "estado" => "S300" "fechaPublicacion" => "2023-01-01" "aid" => "3140" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Arch Bronconeumol. 2023;59:1-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:9 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "The implication of including Interventional Radiologists in multidisciplinary pulmonary embolism treatment teams" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1" "paginaFinal" => "2" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sara Lojo-Lendoiro, Fernando López-Zárraga" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Sara" "apellidos" => "Lojo-Lendoiro" ] 1 => array:2 [ "nombre" => "Fernando" "apellidos" => "López-Zárraga" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289622004835?idApp=UINPBA00003Z" "url" => "/03002896/0000005900000001/v3_202311210639/S0300289622004835/v3_202311210639/en/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "COPD in Women: Future Challenges" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "3" "paginaFinal" => "4" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Victoria Scicluna, MeiLan Han" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Victoria" "apellidos" => "Scicluna" "email" => array:1 [ 0 => "vmah@med.umich.edu" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "MeiLan" "apellidos" => "Han" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, United States" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic obstructive pulmonary disease (COPD) has been a leading cause of death worldwide, but has not garnered the attention it deserves as a major contributor to morbidity and mortality from both a funding and public health perspective. This may be due to misconceptions held both by the medical and lay communities. COPD has traditionally been considered a disease of older men who smoke rather than being recognized as a ubiquitous disease affecting men and women, young and old, smokers and non-smokers. Even the two most recognizable pictorial representations of COPD in the medical literature, the “Blue Bloater” and “Pink Puffer,” depict older men. Meta-analyses estimate the global prevalence of COPD among men is 9–14% and among women 6–8%.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,2</span></a> However, over time, differences in prevalence of COPD between men and women appear to be lessening. Further, women have not experienced the same improvements in mortality that have been seen among men.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,3,4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Smoking, E-Cigarettes and Nicotine Exposures</span><p id="par0010" class="elsevierStylePara elsevierViewall">While smoking remains the leading cause of COPD in all sexes,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> only some of the increase in COPD among women is explained by proportional increases in smoking.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Even when comparing individuals with similar tobacco exposures, women are at greater risk for developing COPD as compared to men.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6,7</span></a> Studies have also shown that women develop COPD with less cigarette exposure and have more severe disease at younger ages than men.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> There are several theories to explain this finding including smaller lung size of women (higher proportion of smoke/particle exposure per given amount of lung tissue), hormonal differences (decline in estrogen levels after menopause leads to alveolar loss), and genetics/epigenetics (altered cell function and pro-inflammatory pathways as a result of various exposures or infections), among others.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,3,4,6,7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite progress toward decreasing traditional combustion smoking over time, a novel threat to the lung health of future generations has risen: increasing use of E-cigarettes. As many as 1 in every 2 adolescents in some countries have reported using E-cigarettes at least once.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> We still do not fully understand the long-term impact of E-cigarettes on lung health. However, we know that they contain as many, if not more, hazardous chemicals than conventional combustion cigarettes.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> Some of these chemicals may ultimately prove to be as harmful as vitamin E acetate, the believed cause of E-cigarette or Vaping Use-Associated Lung Injury (EVALI). In addition, E-cigarettes typically deliver as high or higher amounts of nicotine than combustion cigarettes.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> Evidence suggests that E-cigarette use may serve as a gateway exposure to nicotine in other forms, as it has been associated with increased rates of traditional cigarette smoking over time.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The potential for E-cigarettes to increase nicotine exposure in prenatal settings is another cause for concern which could perpetuate COPD in the next generation. While fetuses do not breathe in the traditional sense, nicotine is able to cross the placenta and nicotine receptors are plentiful in lung tissue.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> Exposure to nicotine in-utero has been associated with impaired lung function in children as old as 12 years, higher rates of asthma and respiratory illnesses, as well as genetic/epigenetic changes (i.e. DNA methylation).<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> Nicotine itself can cause collagen deposition and impacts fetal airway development leading to longer and more tortuous airways that predispose to airflow obstruction.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> Hence, increased nicotine exposure among pregnant women today could significantly increase the risk for COPD in the next generation. This is yet another reason that the long-term consequences of widespread E-cigarette use among young people is truly unknown.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Non-Tobacco Exposures</span><p id="par0025" class="elsevierStylePara elsevierViewall">Unfortunately, data show women are also prone to developing COPD without smoking. Among never-smokers with COPD, more than three-quarters are women.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> The reasons for this are not completely clear. However, men and women do experience differences in exposure to polluted air within the home and at work.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> At an international level, women have historically had greater exposure to indoor pollution caused by biomass fuels/indoor cooking.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> The combustion of these fuels produces fine particles that can be breathed deeply into lungs, especially in poorly ventilated spaces. Other sources of pollution that women may be exposed to in the home include cleaning products, mold/mildew, asbestos, paint, and radon.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> Outside the home, some traditionally female-dominated fields such as textiles, ceramics, and occupations like nail technician or hair dresser can result in exposure to harmful airborne chemicals and particulate matter.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> While it may not be possible to avoid home and occupational exposures altogether, some of the harmful effects could be mitigated by improved ventilation, use of personal protective equipment such as masks, and air purification systems.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Outdoor air pollution is another major future threat for the development of COPD among women.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> The WHO estimates that 99% of the world's population breathes air that exceeds safe pollution limits.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> Environmental pollution is a global crisis which affects many health conditions, but for obvious reasons is particularly worrisome for those of us focused on lung disease. Extreme weather, natural disasters, wildfires, and droughts can cause very high particle levels in the air, even hundreds of miles away from the event itself. Data suggest women may also have increased sensitivity to these environmental exposures.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">COPD Diagnosis and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">In addition to aforementioned issues relating to prevention of COPD, there is also room for improvement of recognition and management of COPD in female patients. Women may not present with the same symptoms or comorbidities as men; they are more likely non-smokers who experience less coughing and phlegm production than men, but have more dyspnea and associated anxiety and depression.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4,15</span></a> Women are also more likely to endorse a delay in diagnosis and greater difficulty in reaching their doctors than men. This is concerning given several studies reporting women also experience more frequent exacerbations than men.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> Providers should be further educated about this data, but we should also continue to investigate and invest in systems-level changes that could improve care delivery and management for COPD in women.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Next Steps</span><p id="par0040" class="elsevierStylePara elsevierViewall">It is true that collectively we face formidable challenges in the fight against COPD including rising nicotine use heralded by E-cigarettes and worsening air quality. Yet, the good news is that women are uniquely positioned to serve as advocates for themselves and the lung health of their children. We can defend the air that future generations will breathe by supporting initiatives such as adoption of cleaner energy strategies for transportation and manufacturing, safer housing (improved ventilation, smoking restrictions, mold mitigation, etc.), anti-idling policies in schools, restrictions on easily inhaled chemicals, and stronger regulation of tobacco products. In the future, we look forward to seeing women taking a stronger role in leadership, not only in politics but also within medicine, as we all work towards reducing the current and future burden of COPD.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Smoking, E-Cigarettes and Nicotine Exposures" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Non-Tobacco Exposures" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "COPD Diagnosis and Treatment" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Next Steps" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gender-specific estimates of COPD prevalence: a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G. Ntritsos" 1 => "J. Franek" 2 => "L. Belbasis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Chron Obstruct Pulmon Dis" "fecha" => "2018" "volumen" => "13" "paginaInicial" => "1507" "paginaFinal" => "1514" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0085" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global and regional estimates of COPD prevalence: Systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Adeloye" 1 => "S. Chua" 2 => "C. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "J Glob Health" "fecha" => "2015" "volumen" => "5" "paginaInicial" => "020415" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0090" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic obstructive pulmonary disease in women: a biologically focused review with a systematic search strategy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.K. Han" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Chron Obstruct Pulmon Dis" "fecha" => "2020" "volumen" => "15" "paginaInicial" => "711" "paginaFinal" => "721" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0095" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Influence of sex on chronic obstructive pulmonary disease risk and treatment outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Aryal" 1 => "E. Diaz-Guzman" 2 => "D.M. Mannino" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Chron Obstruct Pulmon Dis" "fecha" => "2014" "volumen" => "9" "paginaInicial" => "1145" "paginaFinal" => "1154" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0100" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015" ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Lancet Respir Med" "fecha" => "2017" "volumen" => "5" "paginaInicial" => "691" "paginaFinal" => "706" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0105" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sex-specific features of emphysema among current and former smokers with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Hardin" 1 => "M. Foreman" 2 => "M.T. Dransfield" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur Respir J" "fecha" => "2016" "volumen" => "47" "paginaInicial" => "104" "paginaFinal" => "112" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0110" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gender differences in COPD: are women more susceptible to smoking effects than men?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "I.C. Sørheim" 1 => "A. Johannessen" 2 => "A. Gulsvik" 3 => "P.S. Bakke" 4 => "E.K. Silverman" 5 => "D.L. DeMeo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Thorax" "fecha" => "2010" "volumen" => "65" "paginaInicial" => "480" "paginaFinal" => "485" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0115" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Youth vaping: a review and update on global epidemiology, physical and behavioral health risks, and clinical considerations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T.D. Becker" 1 => "T.R. Rice" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur J Pediatr" "fecha" => "2022" "volumen" => "181" "paginaInicial" => "453" "paginaFinal" => "462" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0120" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Breathing lessons: a doctor's guide to lung health" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.K. Han" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:2 [ "fecha" => "2021" "editorial" => "W.W. Norton & Company" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0125" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Smoking intention and progression from e-cigarette use to cigarette smoking" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "O. Owotomo" 1 => "H. Stritzel" 2 => "S.E. McCabe" 3 => "C.J. Boyd" 4 => "J. Maslowsky" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Pediatrics" "fecha" => "2020" "volumen" => "146" "paginaInicial" => "6" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0130" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015" ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Lancet" "fecha" => "2017" "volumen" => "389" "paginaInicial" => "1885" "paginaFinal" => "1906" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0135" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of tobacco smoke and nicotine exposure on lung development" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Gibbs" 1 => "J.M. Collaco" 2 => "S.A. McGrath-Morrow" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Chest" "fecha" => "2016" "volumen" => "149" "paginaInicial" => "552" "paginaFinal" => "561" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0140" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ambient (outdoor) air pollution. Fact sheets" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "WHO" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "Published 2021" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0145" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Air pollution, lung function and COPD: results from the population-based UK Biobank study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Doiron" 1 => "K. de Hoogh" 2 => "N. Probst-Hensch" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Eur Respir J" "fecha" => "2019" "volumen" => "54" "paginaInicial" => "1" ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0150" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gender differences in symptoms and care delivery for chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C.H. Martinez" 1 => "S. Raparla" 2 => "C.A. Plauschinat" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Womens Health (Larchmt)" "fecha" => "2012" "volumen" => "21" "paginaInicial" => "1267" "paginaFinal" => "1274" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03002896/0000005900000001/v3_202311210639/S0300289622004859/v3_202311210639/en/main.assets" "Apartado" => array:4 [ "identificador" => "93863" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorials" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03002896/0000005900000001/v3_202311210639/S0300289622004859/v3_202311210639/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289622004859?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 1 | 10 |
| 2024 October | 67 | 36 | 103 |
| 2024 September | 84 | 24 | 108 |
| 2024 August | 93 | 49 | 142 |
| 2024 July | 79 | 18 | 97 |
| 2024 June | 106 | 34 | 140 |
| 2024 May | 88 | 29 | 117 |
| 2024 April | 58 | 23 | 81 |
| 2024 March | 52 | 21 | 73 |
| 2024 February | 43 | 36 | 79 |
| 2024 January | 37 | 28 | 65 |
| 2023 December | 35 | 34 | 69 |
| 2023 November | 56 | 33 | 89 |
| 2023 October | 51 | 27 | 78 |
| 2023 September | 47 | 38 | 85 |
| 2023 August | 42 | 31 | 73 |
| 2023 July | 45 | 26 | 71 |
| 2023 June | 43 | 15 | 58 |
| 2023 May | 44 | 21 | 65 |
| 2023 April | 63 | 44 | 107 |
| 2023 March | 113 | 39 | 152 |
| 2023 February | 105 | 42 | 147 |
| 2023 January | 256 | 91 | 347 |
| 2022 December | 119 | 47 | 166 |
| 2022 November | 2 | 3 | 5 |
| 2022 October | 1 | 1 | 2 |
| 2022 September | 4 | 4 | 8 |
| 2022 August | 7 | 2 | 9 |
| 2022 July | 2 | 4 | 6 |
Show all
