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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">History of the Evaluation of Activity of Rheumatoid Arthritis&#58; DAS</span><p id="par0005" class="elsevierStylePara elsevierViewall">Throughout history&#44; different scales have been proposed to consistently and uniformly evaluate activity in Rheumatoid Arthritis &#40;RA&#41;&#58; the core set&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the Paulus<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> criteria and the improvement criteria proposed by the American College of Rheumatology &#40;ACR&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">At the beginning of the 1990s&#44; van der Heijde et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> carried out a study with the objective of formulating a composite index that quantified the disease&#46; To that end&#44; they classified a cohort of patients with RA into two groups&#44; according to the decision to modify or reduce treatment with disease modifying anti-rheumatic drugs &#40;DMARD&#41;&#46; Variables that allowed a better differentiation of the 2 situations related to RA activity and obtained a mathematical formula which quantified clinical activity&#44; giving way to the Disease Activity Score<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> &#40;DAS&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The DAS is composed by a measurement of joint pain &#40;Ritchie Index&#44; oscillating between 0 and 78&#41;&#44; a swollen joint index in 44 joints &#40;oscillating between 0 and 44&#41;&#44; ESR and the evaluation of activity by the patient&#44; on a visual analog scale &#40;0&#8211;100<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; There is a modified DAS&#44; the DAS28&#44; based on a 28 painful &#40;PJC&#41; and swollen joint count &#40;SJC&#41;&#44; much more useful in daily clinical practice and is recommended by EULAR&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In order to identify patients with different levels of disease activity&#44; numerical limits were set&#46; Cut points separating the three stages were DAS&#60;2&#46;4 for mild activity and DAS&#62;3&#46;7 for high activity&#44; with moderate activity between them&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Van Riel&#44; extrapolated values for DAS28&#44; with DAS28&#60;3&#46;2 for mild activity and DAS28&#62;5&#46;1 for high activity&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Once the different activity levels were defined&#44; Prevoo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> proposed a cut point for the definition of remission of DAS&#60;1&#46;6&#44; using a modification of the ACR criteria of the ACR&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A few years later&#44; the value of DAS was extrapolated to &#60;2&#46;6 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Usefulness of DAS</span><p id="par0040" class="elsevierStylePara elsevierViewall">There is no exact definition of the concept of usefulness applied to indexes for the follow up of diseases&#46; We frequently say that disease activity evaluation is useful when the results are close to the reality that we intend to measure with the smallest investment possible&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">When questioning the usefulness of DAS28&#44; we should ask two questions&#58; one&#44; if the results approach the real disease activity and two&#44; if the expense&#44; both economical and temporal &#40;time invested&#41; is acceptable&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Real Disease Activity</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Correlation Between the DAS28 Activity and Echography Imaging</span><p id="par0050" class="elsevierStylePara elsevierViewall">During the past decade questions have arisen regarding the correlation between remission criteria according to DaS and echographic remission&#44; showing an important number of false negatives &#40;patients with remission criteria according to DAS but with activity when explored with echography&#41;&#44; especially in mild activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Molenaar et al&#46; in 2004&#44; described in patients&#44; with RA in persistent remission&#44; the radiological progression of structural damage&#44; which means that DAS is not capable of detecting low levels of activity which may be clinically undetectable&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Scire et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> published a study with the objective of evaluating the usefulness of echography in the detection of residual activity in patients with RA&#44; classified as &#8220;remission&#8221; according to DAS&#46; To that end&#44; a prospective study was performed in 106 patients with RA&#44; which received conventional DMARD&#44; in relation to the activity &#40;DAS&#41; for 24 months&#46; The Doppler signal and the gray scale were correlated with the clinical evaluation and the laboratory data&#46; In clinical remission&#44; 95&#37; of the patients showed residual synovitis and 41&#37; of them had a power Doppler signal&#44; showing that echography can detect residual activity better than the physical examination&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Recently&#44; Balsa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">10</span></a> have published a study with the aim of evaluating the proximity between composite indexes classifying patients in remission&#44; using to that end the absence of activity detected by ultrasound as a <span class="elsevierStyleItalic">gold standard</span>&#46; A total of 97 patients with RA were evaluated&#44; catalogued by their rheumatologist as being in &#8220;remission&#8221;&#44; using the DAS28 &#40;remission defined as less than 2&#46;6 and the new value of 2&#46;4&#41; and the SDAI &#40;5 and the new value of 3&#46;3&#41;&#46; Ultrasound examination was carried out in 42 joints&#46; The presence of synovial hypertrophy was found in 92 &#40;94&#46;8&#37;&#41; and power Doppler in 41 &#40;42&#46;3&#37;&#41; patients&#46; If the absence of power Doppler signal is considered as remission&#44; there were no differences between those that presented remission by DAS28 and those that did not&#44; although differences were found in the SDAI&#46; The results suggested that the SDAI definition of &#8220;remission&#8221;&#44; was closer to the concept of the absence of inflammatory activity&#44; defined by the absence of a power Doppler signal in the ultrasound&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Therefore&#44; their results provide proof that current methods&#44; such as DAS&#44; are not necessarily indicators of true inflammatory remission and could explain the progression of structural damage&#44; described in patients in clinical remission&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Evaluation and Weight of Data Employed in the DAS 28 Formula</span><p id="par0075" class="elsevierStylePara elsevierViewall">Belmonte<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> performed a study in 2008 with the objective of studying the relative weight of each variable in the final result of the DAS 28&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">To that end&#44; they tested the value reached by DAS throughout the range of each individual variable&#44; when the rest were set to zero&#46; They observed that the TJC and the ESR provided 35&#37; and 45&#37; respectively&#44; to the value of DAS28&#46; The TJC and global evaluation of the patient contributed 15&#37; only&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Therefore&#44; in spite of the fact that in daily clinical practice we usually give more weight to the SJC than to the TJC&#44; the latter have greater relative weight in the formula&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding the ESR&#44; it is important to emphasize its individual variability and that generated by the different laboratory techniques employed&#46; Another important component is its logarithmic nature&#44; meaning that the lesser the value&#44; the greater its contribution to the formula&#46; Minimal variations&#44; therefore&#44; may produce a leap of almost a whole point in the global index and be the difference between remission and activity or between a good or poor progression&#44; motivating unjustified changes in the therapeutic plan&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">It is important to explain the theoretical &#8220;floor effect&#8221; and the &#8220;ceiling effect&#8221;&#46; According to its original design&#44; the normal DAS range must oscillate continuously between 1 and 10 points&#46; In clinical practice it is difficult to reach values under 1 or over 9&#46; Therefore&#44; with an ESR of 5<span class="elsevierStyleHsp" style=""></span>mm&#44; the DAS28 is 1&#46;13&#44; with no painful or swollen joints and a patient evaluation of zero&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">From a conceptual standpoint&#44; the use of reduced indexes that exclude hips&#44; ankles or feet to evaluate remission has been criticized because they may lead to the cataloguing a patient as being in remission in spite of joint affection&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In 2007&#44; Kapral et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> performed a longitudinal study with 767 patients with Ra&#44; comparing the 32 vs 28 joint counts&#44; excluding in the latter the metatarsophalangeal &#40;MTP&#41; and ankles&#46; In the absence of inflammation&#44; the DAS28 scale had a specificity of 98&#46;1&#37; and a positive predictive value &#40;PPV&#41; 94&#46;1&#37;&#44; and&#44; in the absence of pain&#44; the DAS28 had a specificity and a PPV of 96&#46;1&#37; and 91&#46;7&#37;&#44; respectively&#46; Therefore&#44; the activity index based on the DAS28 may reach levels greater than 2&#46;6 in those patients with feet inflammation because of other values increasing the final result of the index&#44; such as the global evaluation of disease&#46; Therefore&#44; the frequency of remission does not vary when the joint count of 32 becomes 28 in composite indexes&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Invested Resources</span><p id="par0110" class="elsevierStylePara elsevierViewall">Among the components of the formula&#44; the only one that involves an economic expense is the measurement of ESR&#44; although it is cheap and easy to perform&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Even so&#44; it is debatable whether the use of c reactive protein &#40;CRP&#41; would be better to adequately monitor patients with RA&#46; Normally&#44; ESR is not modified as rapidly as CRP&#44; either at the beginning or during the progression of inflammation&#46; In addition&#44; CRP is not as affected as ESR and therefore seems to be a better marker of inflammation&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">There are modifications of DAS that use CRP&#44; formulated for their use in clinical trials&#46; The DAS&#8211;CRP index has been developed as a mathematical approximation to DAS&#44; making its application and use controversial&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">As for the time involved in calculating DAS28&#44; it does not differ greatly from other indexes or test scores employed&#46; For example&#44; 114<span class="elsevierStyleHsp" style=""></span>s are needed to calculate DAS28 compared to 106<span class="elsevierStyleHsp" style=""></span>s needed to calculate CDAI&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">DAS28 has consolidated as a fundamental tool to evaluate RA activity&#46; In contrast with the ACR scores&#44; it is a continuous measurement&#44; lineal&#44; with no need for prior point of reference&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The popularity and the importance of DAS28 are evident not only because it is the currently employed measure in most clinical trials of RA but also because it is included in several clinical practice guidelines for the undertaking of therapeutic decisions&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">On the other hand&#44; we cannot omit mentioning that the DAS is an artifice with which we try to ponder a clinically complex construct&#44; such as RA activity&#46; As with all forms of simplification&#44; it has its inconveniences&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">DAS 28 activity criteria present a respectable number of false negatives&#44; especially at lower activity scores&#46; It has been shown that some patients who are apparently in remission&#44; radiologic progression may be present&#44; detected through imaging techniques such as echography or MRI&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The weight of each variable in the formula may imply important criteria in the final result&#44; such as the case of ESR or the over evaluation of TJC over SJC&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Therefore&#44; and with the new knowledge available&#44; we must become stricter&#44; working on new tools that allow the evaluation of activity in a more precise&#44; flexible and sensible manner&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">However&#44; while a better clinimetric index appears&#44; it would be recommendable to use it as a continuous numerical measure for the evaluation of the intensity of clinical activity in RA&#46;</p></span></span>"
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          "identificador" => "xpalclavsec112831"
          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "xres125537"
          "titulo" => "Resumen"
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        3 => array:2 [
          "identificador" => "xpalclavsec112830"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "History of the Evaluation of Activity of Rheumatoid Arthritis&#58; DAS"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Usefulness of DAS"
          "secciones" => array:2 [
            0 => array:3 [
              "identificador" => "sec0015"
              "titulo" => "Real Disease Activity"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0020"
                  "titulo" => "Correlation Between the DAS28 Activity and Echography Imaging"
                ]
                1 => array:2 [
                  "identificador" => "sec0025"
                  "titulo" => "Evaluation and Weight of Data Employed in the DAS 28 Formula"
                ]
              ]
            ]
            1 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Invested Resources"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Conclusions"
        ]
        7 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2010-10-27"
    "fechaAceptado" => "2010-11-29"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec112831"
          "palabras" => array:4 [
            0 => "Rheumatoid arthritis"
            1 => "DAS"
            2 => "DAS28"
            3 => "Activity"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec112830"
          "palabras" => array:4 [
            0 => "Artritis reumatoide"
            1 => "DAS"
            2 => "DAS28"
            3 => "Actividad"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Rheumatoid arthritis &#40;RA&#41; is a complex systemic joint inflammatory disease with differing manifestations and evolution&#46; A valid&#44; reliable and sensitive assessment procedure that is able to differentiate the inflammatory activity is essential in clinical practice&#44; both in terms of reaching therapeutic decisions and assessing the response to treatment&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The methods currently employed to assess the activity of RA are a combination of clinical parameters&#44; laboratory tests and indicators of the progression of the disease&#44; such as the criteria of the American College of Rheumatology &#40;ACR&#41;&#44; the Disease Activity Score &#40;DAS&#41; and the Simplified Disease Activity Index &#40;SDAI&#41;&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The emergence of new and more effective therapies obliges us to be more demanding in our therapeutic objectives&#44; and therefore to consider the suitability of the methods that we use to follow our patients&#8217; progress&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La artritis reumatoide &#40;AR&#41; es una enfermedad sist&#233;mica inflamatoria articular compleja de diferente presentaci&#243;n y evoluci&#243;n&#46; Una evaluaci&#243;n v&#225;lida&#44; fiable&#44; sensible y diferenciadora de la actividad inflamatoria es esencial en la pr&#225;ctica cl&#237;nica para tomar decisiones terap&#233;uticas y valorar la respuesta al tratamiento&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Los m&#233;todos empleados actualmente para evaluar la actividad de la AR son una combinaci&#243;n de par&#225;metros cl&#237;nicos&#44; de laboratorio e indicadores de la actividad de la enfermedad&#44; como los criterios del <span class="elsevierStyleItalic">American College of Rheumatology</span> &#40;ACR&#41;&#44; el <span class="elsevierStyleItalic">Disease Activity Score</span> &#40;DAS&#41; y el <span class="elsevierStyleItalic">Simplified Disease Activity Index</span> &#40;SDAI&#41;&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La aparici&#243;n de nuevas terapias m&#225;s eficaces&#44; nos obliga a ser m&#225;s exigentes en nuestros objetivos terap&#233;uticos y por tanto&#44; a plantearnos la rentabilidad de los m&#233;todos que utilizamos para el seguimiento de nuestros pacientes&#46;</p>"
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Note&#58; Section credited by the SEAFORMEC with 1&#46;7 credits&#46; To consult questions of every article in&#58; URL&#58; <span class="elsevierStyleInterRef" href="http://www.reumatologiaclinica.org/">http&#58;&#47;&#47;www&#46;reumatologiaclinica&#46;org</span>&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Moya Alvarado P&#44; Laiz A&#46; &#191;Es rentable la utilizaci&#243;n del DAS en el seguimiento cl&#237;nico de los pacientes con artritis reumatoide&#63; Reumatol Clin&#46; 2011&#46; <span class="elsevierStyleInterRef" href="doi:10.1016/j.reuma.2010.11.018">doi&#58;10&#46;1016&#47;j&#46;reuma&#46;2010&#46;11&#46;018</span>&#46;</p>"
      ]
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        "fuente" => "Source&#58; Prevoo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Category&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Original Definition&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Remission&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;1&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Mild activity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Moderate activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">High activity&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">&#62;3&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Remission&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Mild activity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cut Points for the Activity Categories According to DAS and DAS28&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:15 [
            0 => array:3 [
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              "etiqueta" => "1"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The American College of Rheumatology preliminary core set of disease activity measures for rheumatoid arthritis clinical trials&#46; The committee on Outcome Measures in Rheumatoid Arthritis Clinical Trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;T&#46; Felson"
                            1 => "J&#46;J&#46; Anderson"
                            2 => "M&#46; Boers"
                            3 => "C&#46; Bombardier"
                            4 => "M&#46; Chernoff"
                            5 => "B&#46; Frito"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "1993"
                        "volumen" => "36"
                        "paginaInicial" => "729"
                        "paginaFinal" => "740"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8507213"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Analysis of improvement in individual rheumatoid arthritis patients treated with disease-modifying antirheumatic drugs&#44; base don the finding in patients treated with placebo&#46; The corporative systematic Studies of rheumatic Disease Group"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46;E&#46; Paulus"
                            1 => "M&#46;J&#46; Egger"
                            2 => "J&#46;R&#46; Ward"
                            3 => "H&#46;J&#46; Williams"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "1990"
                        "volumen" => "33"
                        "paginaInicial" => "477"
                        "paginaFinal" => "484"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2109613"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "American College of Rheumatology&#46;Preliminary definition of improvement in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;T&#46; Felson"
                            1 => "J&#46;J&#46; Anderson"
                            2 => "M&#46; Boers"
                            3 => "C&#46; Bombardier"
                            4 => "D&#46; Furts"
                            5 => "C&#46; Goldsmith"
                          ]
                        ]
                      ]
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Continuing Medical Education
Is DAS a Profitable Score to Be Used for Rheumatoid Arthritis Patient Follow Up?
¿Es rentable la utilización del DAS en el seguimiento clínico de los pacientes con artritis reumatoide?
Patricia Moya Alvarado
Corresponding author
pmoyaa@santpau.cat

Corresponding author at: Hospital de la Santa Creu i Sant Pau, Unidad de Reumatología. Servicio de Medicina Interna, C/ Mas Casanova, n.° 90, 08025 Barcelona, Spain.
, Ana Laiz
Unidad de Reumatología, Servicio de Medicina Interna, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">History of the Evaluation of Activity of Rheumatoid Arthritis&#58; DAS</span><p id="par0005" class="elsevierStylePara elsevierViewall">Throughout history&#44; different scales have been proposed to consistently and uniformly evaluate activity in Rheumatoid Arthritis &#40;RA&#41;&#58; the core set&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the Paulus<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> criteria and the improvement criteria proposed by the American College of Rheumatology &#40;ACR&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">At the beginning of the 1990s&#44; van der Heijde et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> carried out a study with the objective of formulating a composite index that quantified the disease&#46; To that end&#44; they classified a cohort of patients with RA into two groups&#44; according to the decision to modify or reduce treatment with disease modifying anti-rheumatic drugs &#40;DMARD&#41;&#46; Variables that allowed a better differentiation of the 2 situations related to RA activity and obtained a mathematical formula which quantified clinical activity&#44; giving way to the Disease Activity Score<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> &#40;DAS&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The DAS is composed by a measurement of joint pain &#40;Ritchie Index&#44; oscillating between 0 and 78&#41;&#44; a swollen joint index in 44 joints &#40;oscillating between 0 and 44&#41;&#44; ESR and the evaluation of activity by the patient&#44; on a visual analog scale &#40;0&#8211;100<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; There is a modified DAS&#44; the DAS28&#44; based on a 28 painful &#40;PJC&#41; and swollen joint count &#40;SJC&#41;&#44; much more useful in daily clinical practice and is recommended by EULAR&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In order to identify patients with different levels of disease activity&#44; numerical limits were set&#46; Cut points separating the three stages were DAS&#60;2&#46;4 for mild activity and DAS&#62;3&#46;7 for high activity&#44; with moderate activity between them&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Van Riel&#44; extrapolated values for DAS28&#44; with DAS28&#60;3&#46;2 for mild activity and DAS28&#62;5&#46;1 for high activity&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Once the different activity levels were defined&#44; Prevoo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> proposed a cut point for the definition of remission of DAS&#60;1&#46;6&#44; using a modification of the ACR criteria of the ACR&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A few years later&#44; the value of DAS was extrapolated to &#60;2&#46;6 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Usefulness of DAS</span><p id="par0040" class="elsevierStylePara elsevierViewall">There is no exact definition of the concept of usefulness applied to indexes for the follow up of diseases&#46; We frequently say that disease activity evaluation is useful when the results are close to the reality that we intend to measure with the smallest investment possible&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">When questioning the usefulness of DAS28&#44; we should ask two questions&#58; one&#44; if the results approach the real disease activity and two&#44; if the expense&#44; both economical and temporal &#40;time invested&#41; is acceptable&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Real Disease Activity</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Correlation Between the DAS28 Activity and Echography Imaging</span><p id="par0050" class="elsevierStylePara elsevierViewall">During the past decade questions have arisen regarding the correlation between remission criteria according to DaS and echographic remission&#44; showing an important number of false negatives &#40;patients with remission criteria according to DAS but with activity when explored with echography&#41;&#44; especially in mild activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Molenaar et al&#46; in 2004&#44; described in patients&#44; with RA in persistent remission&#44; the radiological progression of structural damage&#44; which means that DAS is not capable of detecting low levels of activity which may be clinically undetectable&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Scire et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> published a study with the objective of evaluating the usefulness of echography in the detection of residual activity in patients with RA&#44; classified as &#8220;remission&#8221; according to DAS&#46; To that end&#44; a prospective study was performed in 106 patients with RA&#44; which received conventional DMARD&#44; in relation to the activity &#40;DAS&#41; for 24 months&#46; The Doppler signal and the gray scale were correlated with the clinical evaluation and the laboratory data&#46; In clinical remission&#44; 95&#37; of the patients showed residual synovitis and 41&#37; of them had a power Doppler signal&#44; showing that echography can detect residual activity better than the physical examination&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Recently&#44; Balsa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">10</span></a> have published a study with the aim of evaluating the proximity between composite indexes classifying patients in remission&#44; using to that end the absence of activity detected by ultrasound as a <span class="elsevierStyleItalic">gold standard</span>&#46; A total of 97 patients with RA were evaluated&#44; catalogued by their rheumatologist as being in &#8220;remission&#8221;&#44; using the DAS28 &#40;remission defined as less than 2&#46;6 and the new value of 2&#46;4&#41; and the SDAI &#40;5 and the new value of 3&#46;3&#41;&#46; Ultrasound examination was carried out in 42 joints&#46; The presence of synovial hypertrophy was found in 92 &#40;94&#46;8&#37;&#41; and power Doppler in 41 &#40;42&#46;3&#37;&#41; patients&#46; If the absence of power Doppler signal is considered as remission&#44; there were no differences between those that presented remission by DAS28 and those that did not&#44; although differences were found in the SDAI&#46; The results suggested that the SDAI definition of &#8220;remission&#8221;&#44; was closer to the concept of the absence of inflammatory activity&#44; defined by the absence of a power Doppler signal in the ultrasound&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Therefore&#44; their results provide proof that current methods&#44; such as DAS&#44; are not necessarily indicators of true inflammatory remission and could explain the progression of structural damage&#44; described in patients in clinical remission&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Evaluation and Weight of Data Employed in the DAS 28 Formula</span><p id="par0075" class="elsevierStylePara elsevierViewall">Belmonte<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> performed a study in 2008 with the objective of studying the relative weight of each variable in the final result of the DAS 28&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">To that end&#44; they tested the value reached by DAS throughout the range of each individual variable&#44; when the rest were set to zero&#46; They observed that the TJC and the ESR provided 35&#37; and 45&#37; respectively&#44; to the value of DAS28&#46; The TJC and global evaluation of the patient contributed 15&#37; only&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Therefore&#44; in spite of the fact that in daily clinical practice we usually give more weight to the SJC than to the TJC&#44; the latter have greater relative weight in the formula&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding the ESR&#44; it is important to emphasize its individual variability and that generated by the different laboratory techniques employed&#46; Another important component is its logarithmic nature&#44; meaning that the lesser the value&#44; the greater its contribution to the formula&#46; Minimal variations&#44; therefore&#44; may produce a leap of almost a whole point in the global index and be the difference between remission and activity or between a good or poor progression&#44; motivating unjustified changes in the therapeutic plan&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">It is important to explain the theoretical &#8220;floor effect&#8221; and the &#8220;ceiling effect&#8221;&#46; According to its original design&#44; the normal DAS range must oscillate continuously between 1 and 10 points&#46; In clinical practice it is difficult to reach values under 1 or over 9&#46; Therefore&#44; with an ESR of 5<span class="elsevierStyleHsp" style=""></span>mm&#44; the DAS28 is 1&#46;13&#44; with no painful or swollen joints and a patient evaluation of zero&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">From a conceptual standpoint&#44; the use of reduced indexes that exclude hips&#44; ankles or feet to evaluate remission has been criticized because they may lead to the cataloguing a patient as being in remission in spite of joint affection&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In 2007&#44; Kapral et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> performed a longitudinal study with 767 patients with Ra&#44; comparing the 32 vs 28 joint counts&#44; excluding in the latter the metatarsophalangeal &#40;MTP&#41; and ankles&#46; In the absence of inflammation&#44; the DAS28 scale had a specificity of 98&#46;1&#37; and a positive predictive value &#40;PPV&#41; 94&#46;1&#37;&#44; and&#44; in the absence of pain&#44; the DAS28 had a specificity and a PPV of 96&#46;1&#37; and 91&#46;7&#37;&#44; respectively&#46; Therefore&#44; the activity index based on the DAS28 may reach levels greater than 2&#46;6 in those patients with feet inflammation because of other values increasing the final result of the index&#44; such as the global evaluation of disease&#46; Therefore&#44; the frequency of remission does not vary when the joint count of 32 becomes 28 in composite indexes&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Invested Resources</span><p id="par0110" class="elsevierStylePara elsevierViewall">Among the components of the formula&#44; the only one that involves an economic expense is the measurement of ESR&#44; although it is cheap and easy to perform&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Even so&#44; it is debatable whether the use of c reactive protein &#40;CRP&#41; would be better to adequately monitor patients with RA&#46; Normally&#44; ESR is not modified as rapidly as CRP&#44; either at the beginning or during the progression of inflammation&#46; In addition&#44; CRP is not as affected as ESR and therefore seems to be a better marker of inflammation&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">There are modifications of DAS that use CRP&#44; formulated for their use in clinical trials&#46; The DAS&#8211;CRP index has been developed as a mathematical approximation to DAS&#44; making its application and use controversial&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">As for the time involved in calculating DAS28&#44; it does not differ greatly from other indexes or test scores employed&#46; For example&#44; 114<span class="elsevierStyleHsp" style=""></span>s are needed to calculate DAS28 compared to 106<span class="elsevierStyleHsp" style=""></span>s needed to calculate CDAI&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">DAS28 has consolidated as a fundamental tool to evaluate RA activity&#46; In contrast with the ACR scores&#44; it is a continuous measurement&#44; lineal&#44; with no need for prior point of reference&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The popularity and the importance of DAS28 are evident not only because it is the currently employed measure in most clinical trials of RA but also because it is included in several clinical practice guidelines for the undertaking of therapeutic decisions&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">On the other hand&#44; we cannot omit mentioning that the DAS is an artifice with which we try to ponder a clinically complex construct&#44; such as RA activity&#46; As with all forms of simplification&#44; it has its inconveniences&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">DAS 28 activity criteria present a respectable number of false negatives&#44; especially at lower activity scores&#46; It has been shown that some patients who are apparently in remission&#44; radiologic progression may be present&#44; detected through imaging techniques such as echography or MRI&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The weight of each variable in the formula may imply important criteria in the final result&#44; such as the case of ESR or the over evaluation of TJC over SJC&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Therefore&#44; and with the new knowledge available&#44; we must become stricter&#44; working on new tools that allow the evaluation of activity in a more precise&#44; flexible and sensible manner&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">However&#44; while a better clinimetric index appears&#44; it would be recommendable to use it as a continuous numerical measure for the evaluation of the intensity of clinical activity in RA&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Rheumatoid arthritis &#40;RA&#41; is a complex systemic joint inflammatory disease with differing manifestations and evolution&#46; A valid&#44; reliable and sensitive assessment procedure that is able to differentiate the inflammatory activity is essential in clinical practice&#44; both in terms of reaching therapeutic decisions and assessing the response to treatment&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The methods currently employed to assess the activity of RA are a combination of clinical parameters&#44; laboratory tests and indicators of the progression of the disease&#44; such as the criteria of the American College of Rheumatology &#40;ACR&#41;&#44; the Disease Activity Score &#40;DAS&#41; and the Simplified Disease Activity Index &#40;SDAI&#41;&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The emergence of new and more effective therapies obliges us to be more demanding in our therapeutic objectives&#44; and therefore to consider the suitability of the methods that we use to follow our patients&#8217; progress&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Note&#58; Section credited by the SEAFORMEC with 1&#46;7 credits&#46; To consult questions of every article in&#58; URL&#58; <span class="elsevierStyleInterRef" href="http://www.reumatologiaclinica.org/">http&#58;&#47;&#47;www&#46;reumatologiaclinica&#46;org</span>&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Moya Alvarado P&#44; Laiz A&#46; &#191;Es rentable la utilizaci&#243;n del DAS en el seguimiento cl&#237;nico de los pacientes con artritis reumatoide&#63; Reumatol Clin&#46; 2011&#46; <span class="elsevierStyleInterRef" href="doi:10.1016/j.reuma.2010.11.018">doi&#58;10&#46;1016&#47;j&#46;reuma&#46;2010&#46;11&#46;018</span>&#46;</p>"
      ]
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                  \t\t\t\t">Mild activity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;2&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Moderate activity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">High activity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#62;3&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;2&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Mild activity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;3&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#62;5&#46;5&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cut Points for the Activity Categories According to DAS and DAS28&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:15 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The American College of Rheumatology preliminary core set of disease activity measures for rheumatoid arthritis clinical trials&#46; The committee on Outcome Measures in Rheumatoid Arthritis Clinical Trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;T&#46; Felson"
                            1 => "J&#46;J&#46; Anderson"
                            2 => "M&#46; Boers"
                            3 => "C&#46; Bombardier"
                            4 => "M&#46; Chernoff"
                            5 => "B&#46; Frito"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "1993"
                        "volumen" => "36"
                        "paginaInicial" => "729"
                        "paginaFinal" => "740"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8507213"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Analysis of improvement in individual rheumatoid arthritis patients treated with disease-modifying antirheumatic drugs&#44; base don the finding in patients treated with placebo&#46; The corporative systematic Studies of rheumatic Disease Group"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46;E&#46; Paulus"
                            1 => "M&#46;J&#46; Egger"
                            2 => "J&#46;R&#46; Ward"
                            3 => "H&#46;J&#46; Williams"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "1990"
                        "volumen" => "33"
                        "paginaInicial" => "477"
                        "paginaFinal" => "484"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2109613"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "American College of Rheumatology&#46;Preliminary definition of improvement in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;T&#46; Felson"
                            1 => "J&#46;J&#46; Anderson"
                            2 => "M&#46; Boers"
                            3 => "C&#46; Bombardier"
                            4 => "D&#46; Furts"
                            5 => "C&#46; Goldsmith"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "1995"
                        "volumen" => "38"
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                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Judging disease activity in clinical practice in rheumatoid arthritis&#58; first step in the development of disease activity score"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;M&#46; Van der Heijde"
                            1 => "M&#46;A&#46; Van &#8216;t Hof"
                            2 => "P&#46;L&#46; Van Riel"
                            3 => "L&#46;A&#46; Theunisse"
                            4 => "E&#46;W&#46; Lubberts"
                            5 => "M&#46;A&#46; van Leeuwen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "1990"
                        "volumen" => "49"
                        "paginaInicial" => "916"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2256738"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
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            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Modified disease activity scores that include twenty-eight-joint counts&#58; developmnet and validation in a prospective longitudinal study of patients with rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;L&#46;L&#46; Prevoo"
                            1 => "M&#46;A&#46; Van&#8216;t Hof"
                            2 => "H&#46;H&#46; Kuper"
                            3 => "M&#46;A&#46; Van Leeuwen"
                            4 => "L&#46;B&#46; Van de Putte"
                            5 => "P&#46;L&#46; Van Riel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "1995"
                        "volumen" => "38"
                        "paginaInicial" => "44"
                        "paginaFinal" => "48"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7818570"
                            "web" => "Medline"
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              "etiqueta" => "6"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Is DAS28 an appropriate tool to asses remission in rheumatoid arthritis&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46; Makinen"
                            1 => "H&#46; Kautianen"
                            2 => "P&#46; Hannonen"
                            3 => "T&#46; Sokka"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Ann Reum Dis"
                        "fecha" => "2005"
                        "volumen" => "64"
                        "paginaInicial" => "1410"
                        "paginaFinal" => "1413"
                      ]
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                  ]
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              "etiqueta" => "7"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#191;Son necesarias las t&#233;cnicas de imagen para definir la remisi&#243;n en la artritis reumatoide&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "E&#46; Naredo S&#225;nchez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Reumatol Clin"
                        "fecha" => "2009"
                        "volumen" => "05"
                        "paginaInicial" => "17"
                        "paginaFinal" => "21"
                      ]
                    ]
                  ]
                ]
              ]
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            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Progression of radiologic damage in patients with rheumatoid arthritis in clinical remission"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46;T&#46; Molenaar"
                            1 => "A&#46;E&#46; Voskuyl"
                            2 => "H&#46;J&#46; Dinant"
                            3 => "P&#46;D&#46; Bezemer"
                            4 => "M&#46; Boers"
                            5 => "B&#46;A&#46; Dijkmans"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/art.11481"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2004"
                        "volumen" => "50"
                        "paginaInicial" => "36"
                        "paginaFinal" => "42"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14730597"
                            "web" => "Medline"
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              ]
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              "etiqueta" => "9"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasonographic evaluation of joint involvement in early rheumatoid arthritis in clinical remission&#58; power doppler signal predicts short-term relapse"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46; Scire"
                            1 => "C&#46; Montecucco"
                            2 => "V&#46; Codullo"
                            3 => "O&#46; Epis"
                            4 => "M&#46; Todoerti"
                            5 => "R&#46; Caporali"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/kep171"
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                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2009"
                        "volumen" => "48"
                        "paginaInicial" => "1092"
                        "paginaFinal" => "1097"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19561156"
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              "identificador" => "bib0080"
              "etiqueta" => "10"
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Article information
ISSN: 21735743
Original language: English
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