Letter to the Editor
Acute renal failure as a debut manifestation in Still's disease
Insuficiencia renal aguda como manifestación inicial en la enfermedad de Still
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"tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "648" "paginaFinal" => "649" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Vasculitis ANCA positivas y Enfermedad relacionada con IgG4: ¿un síndrome de superposición o dos enfermedades distintas?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 814 "Ancho" => 2092 "Tamanyo" => 261712 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Renal biopsy specimen. (A) Light microscopy shows a severe interstitial lymphoplasmacytic infiltrate (H&E, 20×). (B) The immunohistochemical study revels<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>30 IgG4 positive plasmocytes per large magnification field (IgG 4 immunohistochemistry, 40×).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Inês Sala, Joana Freitas, João Oliveira, Josefina Santos, Ana Castro, António Cabrita" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Inês" "apellidos" => "Sala" ] 1 => array:2 [ "nombre" => "Joana" "apellidos" => "Freitas" ] 2 => array:2 [ "nombre" => "João" "apellidos" => "Oliveira" ] 3 => array:2 [ "nombre" => "Josefina" "apellidos" => "Santos" ] 4 => array:2 [ "nombre" => "Ana" "apellidos" => "Castro" ] 5 => array:2 [ "nombre" => "António" "apellidos" => "Cabrita" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251422001468?idApp=UINPBA000064" "url" => "/20132514/0000004300000005/v1_202312041752/S2013251422001468/v1_202312041752/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2013251422001286" "issn" => "20132514" "doi" => "10.1016/j.nefroe.2021.07.009" "estado" => "S300" "fechaPublicacion" => "2023-09-01" "aid" => "969" "copyright" => "Sociedad Española de Nefrología" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Nefrologia (English Version). 2023;43:643-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Acute kidney injury with sodium-glucose co-transporter-2 inhibitors across the cardiovascular and renal outcome trials: Foe or friend?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "643" "paginaFinal" => "645" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Daño renal agudo con cotransportador de sodio-glucosa-2 inhibidores en el resultado cardiovascular y renal ensayos: enemigo o amigo?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1840 "Ancho" => 2925 "Tamanyo" => 436344 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Effect of SGLT-2 inhibitors compared to control on the risk of AKI across the cardiovascular and renal outcome trials and the trials performed in the heart failure population.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Dimitrios Patoulias, Christodoulos Papadopoulos, Fotios Siskos, Michael Doumas" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Dimitrios" "apellidos" => "Patoulias" ] 1 => array:2 [ "nombre" => "Christodoulos" "apellidos" => "Papadopoulos" ] 2 => array:2 [ "nombre" => "Fotios" "apellidos" => "Siskos" ] 3 => array:2 [ "nombre" => "Michael" "apellidos" => "Doumas" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251422001286?idApp=UINPBA000064" "url" => "/20132514/0000004300000005/v1_202312041752/S2013251422001286/v1_202312041752/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Acute renal failure as a debut manifestation in Still's disease" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "645" "paginaFinal" => "647" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Samuel Blas Gómez, Fernando Mateos Rodríguez, María Luisa Illescas Fernández-Bermejo, Syonghyun Nam Cha, Julián Solís García del Pozo" "autores" => array:5 [ 0 => array:3 [ "nombre" => "Samuel" "apellidos" => "Blas Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Fernando" "apellidos" => "Mateos Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "María Luisa" "apellidos" => "Illescas Fernández-Bermejo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Syonghyun" "apellidos" => "Nam Cha" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:4 [ "nombre" => "Julián" "apellidos" => "Solís García del Pozo" "email" => array:1 [ 0 => "julianeloysolis@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Nephrology, Albacete University Hospital Complex, Albacete, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Infectious Diseases, Albacete University Hospital Complex, Albacete, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Pathology, Albacete University Hospital Complex, Albacete, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Insuficiencia renal aguda como manifestación inicial en la enfermedad de Still" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1397 "Ancho" => 1874 "Tamanyo" => 335905 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Renal biopsy images: (A) Image showing glomeruli with mostly normal characteristics; (B) image showing acute interstitial infiltrate with a predominance of lymphocytes and eosinophils together with some ruptured tubules; (C) Image showing positivity of anti-IgA immunofixation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Adult Still's disease (ASD) is a systemic inflammatory disease of unknown etiology. Renal involvement in ASD is a rare and rarely reported manifestation in the literature. This report presents an atypical case of ASD with acute renal failure.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 39-year-old male with arterial hypertension treated with Ramipril 10<span class="elsevierStyleHsp" style=""></span>mg was admitted to the Emergency Department (ED) with a fever of up to 39<span class="elsevierStyleHsp" style=""></span>°C, right laterocervical edema, dysphagia, and odynophagia the last four days. He started treatment with Amoxicillin-Clavulanate before consultation in the ED. The patient did not report country outings or recent trips. He highlighted an infestation of rodents in his building. The patient denied consuming alcohol, tobacco and other drugs, or mushrooms, herbal products, or other substances that could have caused liver damage.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed mild jaundice, a temperature of 38<span class="elsevierStyleHsp" style=""></span>°C, non-adhered right laterocervical lymphadenopathy of 1–2<span class="elsevierStyleHsp" style=""></span>cm, enlarged tonsils with discrete whitish plaques on their surface, and a macular and itchy rash on the upper trunk and forearms. Laboratory tests at ED showed: procalcitonin 1.10<span class="elsevierStyleHsp" style=""></span>ng/ml, urea 69<span class="elsevierStyleHsp" style=""></span>mg/dL, creatinine 2.79<span class="elsevierStyleHsp" style=""></span>mg/dL, sodium 135<span class="elsevierStyleHsp" style=""></span>mmol/L, potassium 4.5<span class="elsevierStyleHsp" style=""></span>mmol/L, chlorine 98<span class="elsevierStyleHsp" style=""></span>mmol/L, GPT 114<span class="elsevierStyleHsp" style=""></span>U/L, CK 233<span class="elsevierStyleHsp" style=""></span>U/L, Amylase 35<span class="elsevierStyleHsp" style=""></span>U/L, C reactive protein (CRP) 286.9<span class="elsevierStyleHsp" style=""></span>mg/L, leukocytes 15,430/mcL (neutrophils 13,740/mcL), prothrombin activity 63%. Abdominal ultrasound and chest X-ray were normal. The patient presented the day after admission: total bilirubin 9<span class="elsevierStyleHsp" style=""></span>mg/dL, direct bilirubin 8.4<span class="elsevierStyleHsp" style=""></span>mg/dL, GGT 143<span class="elsevierStyleHsp" style=""></span>IU/L, and Alkaline Phosphatase 267<span class="elsevierStyleHsp" style=""></span>IU/L. Leukocytosis reached 33,000/mcL with 92% polymorphonuclear cells. The rise in ferritin levels was remarkable with 4.104 mcg/mL. During admission, the patient presented a rapid onset acute renal failure with anuria. The renal function worsened with a creatinine of 10.36<span class="elsevierStyleHsp" style=""></span>mg/dL. This clinical course led to hemodialysis therapy from the second day of admission.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Immunoglobulin A level was 479<span class="elsevierStyleHsp" style=""></span>mg/dL. C3, C4, Antistreptolysin O, antinuclear antibodies, nuclear extractible antigen antibodies, anti-DNA antibodies, neutrophil anti-cytoplasmic antibodies were normal or negative. Interleukin-6 was 148<span class="elsevierStyleHsp" style=""></span>pg/mL. Plasma protein electrophoresis was compatible with an acute inflammatory process.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Nasopharyngeal swab for Polymerase Chain Reaction for SARS-CoV2 and pharyngeal swab for <span class="elsevierStyleItalic">Streptococcus pyogenes</span> were both negative. Urine and blood cultures were negative. Serologic studies ruled out acute infection by Cytomegalovirus, Epstein-Bar virus, Measles, Q fever, Leptospira, hepatitis A and B viruses, Human Immunodeficiency Virus, and parvovirus B19. A computed tomography (CT) scan showed a slightly enlarged 15-cm spleen. A Positron Emission Tomography-CT scan was normal.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally, a renal biopsy showed an acute tubulointerstitial inflammatory infiltrate with some ruptured tubule and isolated eosinophils associated with a dense lymphoplasmacytic infiltrate and a mesangial deposit anti-IgA (++) and minimal anti-C3, all of which was compatible with IgA mesangial nephropathy and acute tubulointerstitial nephritis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). However, there was an absence of intratubular erythrocyte casts or crescents in the biopsy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Our patient meets the criteria of both Yamaguchi and Fautrel for presumptive diagnosis of ASD (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Corticosteroid treatment was started initially with Prednisone 60<span class="elsevierStyleHsp" style=""></span>mg/day, and subsequently escalating to 500<span class="elsevierStyleHsp" style=""></span>mg of 6-Methylprednisolone daily associated with Anakinra at 100<span class="elsevierStyleHsp" style=""></span>mg/week, causing a rapid and progressive improvement in the general condition and rash, a decrease in the acute phase reactants and leukocytosis, and an improvement in his renal function. The patient recovered normal diuresis and was discharged with a creatinine of 2.04<span class="elsevierStyleHsp" style=""></span>mg/dL with proteinuria of 25<span class="elsevierStyleHsp" style=""></span>mg/dL in basic urine examination. After discharge from the hospital, the patient fully recovers renal function with a creatinine of 1<span class="elsevierStyleHsp" style=""></span>mg/dL.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Since there are currently no specific diagnostic tests, ASD diagnosis is usually based on the clinical recognition of the entity, always ruling out other possible etiologies such as infections or neoplasms. Among the criteria used for its diagnosis are the Yamaguchi criteria<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> and the Fautrel criteria<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Elevated procalcitonin, C-reactive protein, and leukocytosis with neutrophilia could lead the clinician to suspect other etiologies, especially infectious, and diagnostic delay. Serum ferritin or cytokines, such as IL-6, can help diagnosis. The combination that has shown the greatest diagnostic accuracy was serum ferritin<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1000<span class="elsevierStyleHsp" style=""></span>mcg/L or values five times above the upper limit of normal, together with a fraction of glycated ferritin<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>20%. Its sensitivity and specificity are 70.5% and 92.9%, respectively.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Still's disease can present more atypical manifestations, such as acute renal failure of rapid onset. Entities associated in previous literature were Amyloidosis,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Thrombotic Microangiopathy,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> IgA Glomerulonephritis,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> and more recently, cases of collapsing glomerulopathy.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> However, despite being described in reviews on Still's disease,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> only one case of interstitial nephritis has been found reported in the consulted bibliography.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Therefore, it is essential to include ASD in the differential diagnoses of acute renal failure accompanied by analytical markers such as elevated IL-6 or ferritin of up to five times its standard value. Early treatment of this disease can lead to the complete recovery of the patient's previous renal function.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Informed consent</span><p id="par0055" class="elsevierStylePara elsevierViewall">The patient reported here has provided written informed consent for publication of this case report.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">This work has no funding.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Informed consent" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1397 "Ancho" => 1874 "Tamanyo" => 335905 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Renal biopsy images: (A) Image showing glomeruli with mostly normal characteristics; (B) image showing acute interstitial infiltrate with a predominance of lymphocytes and eosinophils together with some ruptured tubules; (C) Image showing positivity of anti-IgA immunofixation.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:2 [ 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="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Criteria of Yamaguchi et al. [4]<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></th></tr></thead><tbody title="tbody"><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="elsevierStyleItalic">Major criteria</span>:- Fever<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>39<span class="elsevierStyleHsp" style=""></span>°C<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>1 week- Arthralgias/Arthritis for 2 or more weeks- Typical evanescent rash- Leukocytosis<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>10,000/mm<span class="elsevierStyleSup">3</span> with ≥80% polymorphonuclear \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"><span class="elsevierStyleItalic">Minor criteria</span>:- Odynophagia- Lymphadenopathy- Splenomegaly- Alteration of liver function tests- Rheumatoid factor and ANA negatives \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3383553.png" ] ] 1 => 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="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Criteria of Fautrel et al. [5]<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></th></tr></thead><tbody title="tbody"><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="elsevierStyleItalic">Major criteria</span>:- Spiking fever<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>39<span class="elsevierStyleHsp" style=""></span>°C- Arthralgia- Transient skin rash- Odynophagia- Polymorphonuclear cells<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>80%- Glycated ferritin<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>20% \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"><span class="elsevierStyleItalic">Minor criteria</span>:- Maculopapular rash- Leukocytosis<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>10,000/mm<span class="elsevierStyleSup">3</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3383552.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">5 or more of these criteria, of which at least 2 major criteria, establishes the diagnosis of the disease (sensitivity of 96.2% and specificity of 92.1%). Infections, neoplasms, and other systemic diseases that can simulate an ASD should be excluded.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">4 or more major criteria or 3 major<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>2 minor criteria are needed for diagnosis.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diagnostic criteria of ASD.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preliminary criteria for classification of adult Still's disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 9 | 20 |
| 2024 October | 70 | 47 | 117 |
| 2024 September | 82 | 37 | 119 |
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| 2024 July | 45 | 36 | 81 |
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| 2024 May | 62 | 40 | 102 |
| 2024 April | 48 | 32 | 80 |
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| 2024 January | 935 | 36 | 971 |
| 2023 December | 54 | 39 | 93 |
| 2023 November | 35 | 36 | 71 |
| 2023 October | 33 | 30 | 63 |
| 2023 September | 30 | 32 | 62 |
| 2023 August | 25 | 33 | 58 |
| 2023 July | 26 | 34 | 60 |
| 2023 June | 25 | 16 | 41 |
| 2023 May | 26 | 32 | 58 |
| 2023 April | 23 | 26 | 49 |
| 2023 March | 20 | 24 | 44 |
| 2023 February | 17 | 22 | 39 |
| 2023 January | 27 | 42 | 69 |
| 2022 December | 33 | 39 | 72 |
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