Original article
Frequency of Complications and Usefulness of the Minor Salivary Gland Biopsy
Frecuencia de complicaciones y rédito de la biopsia de glándula salival menor
María Lida Santiago, María Renata Seisdedos
, Rodrigo Nicolás García Salinas, Anastasia Secco, Lucila Marino Claverie, Lorena Techera, Lorena Takashima, Pedro Aicardi, Marco Antonio Sandi Rosales, Elizabeth Knobel, Sebastián Juan Magri, Antonio Carlos Catalán Pellet
Corresponding author
Servicio de Reumatología, Hospital Bernardino Rivadavia, Ciudad Autónoma de Buenos Aires, Argentina
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SS may occur alone (primary SS [pSS]) or associated with other autoimmune diseases (secondary SS).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The histopathology of the salivary glands as a part of diagnosis was proposed first in 1970 by Waterhouse, Chisholm, and Mason, the latter established a score based on inflammatory<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> cell aggregates.</p><p id="par0015" class="elsevierStylePara elsevierViewall">According to the European-American<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> criteria for diagnosis of pSS, the presence of a SGB compatible with the disease and/or the presence of antibodies anti-Ro/anti-La is needed. The MSGB is also a method for diagnosing diseases such as infiltrative amiloidosis<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and sarcoidosis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Numerous surgical techniques have been described. They vary according to size from 1.5<span class="elsevierStyleHsp" style=""></span>mm to 30<span class="elsevierStyleHsp" style=""></span>mm, the shape of the incision (elliptical, horizontal, vertical, and wedge), and localization.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> While this is an invasive procedure, it is easy to perform and has a low frequency complications.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Caporali et al. described transient adverse effects in 64 (12.7%) cases in their series of 502 procedures: paresthesias (57), hematoma (8), local swelling (27), and others (5).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In other studies sensory disturbances (anesthesia, paresthesia) are described as the complications encountered with greater frequency, being transient in most cases. However, other authors have reported no complications.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">As for the sample collected, 99% is needed to be considered as the material is useful for study.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Despite the simplicity of the technique, MSGB is not incorporated in daily practice in all centers. Although other authors have reported complication rates of the different techniques and usefulness of the procedure, we consider important to evaluate the safety and yield (obtaining suitable material for pathology) of the method in our center.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In this paper we estimate the percentage of mediate and immediate complications of MSGB and frequency of obtaining suitable material for pathology.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and Methods</span><p id="par0045" class="elsevierStylePara elsevierViewall">We designed a prospective, observational, descriptive, and longitudinal study.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We included patients referred with suspected SS and who underwent MSGB. Patients should have no evidence of coagulation disorders and a platelet count within normal within 1 month before the procedure.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Exclusion criteria were: use of aspirin or other NSAIDs 1 week before the study, clinical signs of local infection, patients on anticoagulants, and those who refused inclusion in the protocol.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The study was approved by the Ethics Committee of the hospital. All patients signed an informed consent.</p><p id="par0065" class="elsevierStylePara elsevierViewall">We prospectively studied MSGB conducted between October 2007 and May 2010, at the Rheumatology Service of Hospital Bernardino Rivadavia City of Buenos Aires, Argentina.</p><p id="par0070" class="elsevierStylePara elsevierViewall">All patients underwent minor salivary gland biopsy with the surgical technique described by Caporali et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The material obtained was preserved in 10% formalin and sent for analysis to pathology.</p><p id="par0080" class="elsevierStylePara elsevierViewall">We analyzed the characteristics of the incision and any complications during the procedure and after it. The patient was followed up a week and a month after the procedure. The yield was evaluated through the results of the pathology.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Measurements: immediate complications: bleeding that obstructs the proceedings, fainting, accidents due to health staff while performing the procedure. Mediate complications: surgical wound infection, suture dehiscence, sensory disturbances (dysesthesia, anesthesia, paresthesia), defective wound healing, as defined by the presence of granuloma or keloid scarring at the site.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical Analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">Complications were studied with a frequency analysis and calculation of confidence intervals of 95%.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">We included 186 procedures performed between October 2007 and May 2010, of which 29 were performed to confirm the diagnosis of secondary SS and the rest of pSS. Among patients with suspected secondary SS, 21 had a diagnosis of rheumatoid arthritis (RA), 3 systemic lupus erythematosus (SLE), 3 primary biliary cirrhosis (PBC), 1 mixed connective tissue disease (MCTD) and 1 of cryoglobulinemic vasculitis. The clinical and serological features are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Of the 14 (7.5%) patients receiving immunosuppressive therapy at the time of the procedure, 11 received methotrexate (9 of them had a diagnosis of RA), 1 leflunomide and 1 azathioprine.</p><p id="par0105" class="elsevierStylePara elsevierViewall">All patients tolerated the procedure and no serious adverse events were recorded. 15 patients had postoperative complications (8.1%, 95% CI, 4.7–13.2). Complications included: bleeding 7.5%, fainting 3.2%, hematoma 2.7%. There were no accidents (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">There were 164 patients who attended follow-up visits a week and a month after the procedure. Mediate complications were found in 16 patients (9.75%, 95% CI, 5.9–15.6), distributed as follows: pain 7.32%, inflammatory signs 3.66%, sensory loss 3.05%, and granuloma 1.22%. Sensitivity disorders were transient. No cases of infections or dehiscence of the suture were seen.</p><p id="par0115" class="elsevierStylePara elsevierViewall">At the time of analysis, we had the pathology report of 154 biopsies and in 140 (90.9%, 95% CI, 85–95) glandular material was obtained (typically minor salivary glands, lipomatosis, chronic nonspecific sialadenitis, grade III and IV infiltrates), and in other cases fibromuscular tissue and fat or little material was obtained.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">Establishing the diagnosis of SS has some difficulty due to the low specificity and sensitivity of serological markers and the lack of specific symptoms of the syndrome. To date, different classification criteria have been proposed, which are based on a combination of clinical, serological, and histologic data.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,9–13</span></a> There are some differences between the San Francisco<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> (which is based on the histopathology) and San Diego<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> criteria, where the MSGB is essential to reach the diagnosis of SS, as well as the Copenhague,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> the Greek,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Japanese,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and European<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> community criteria, which do not require MSGB or the presence of antibodies, or the American-European criteria 2002,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> which require the presence of histological or serological criteria. Minor salivary gland biopsy is therefore essential for diagnosis in patients with negative suspected SS autoantibodies.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The importance of MSGB is stressed for differential diagnosis with other pathologies and it is currently proposed that the lymphoid organization be a marker for the development of Hodgkin's<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> lymphoma.</p><p id="par0130" class="elsevierStylePara elsevierViewall">MSGB is a technically simple procedure and complications are rare. Furthermore, with the technique presented, 90.9% of the material obtained was useful for pathology, somewhat lower than that described by Caporali et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> (99.2%) and Teppo–Revonta<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> (98.4%).</p><p id="par0135" class="elsevierStylePara elsevierViewall">This study describes a high prevalence of immediate complications of 8.1% and 9.75% mediate complications, showing the reliability of both health personnel and patients, since there were no serious or medium or long term complications during the procedure. Within a week, 12 patients reported pain and 6 had inflammatory signs during the first days, 5 had mild sensory loss, which disappeared within a month, and in 2 of them we found the formation of granuloma.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Several observations analyzed MSGB with a technique similar to that used in this study and obtained comparable results; the complications were uncommon, and the most prevalent were paresthesias at the site of incision, transient in nature, in most the patients.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Richards et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> reported 2 cases of disorders of sensation at the incision site, which persisted beyond 1 year, with mild features and no objective evidence of neurological disease, while Berquin et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> described anesthesia in 1 case and Marx et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> reported 3 cases of which one was persistent after 2 years of follow-up. Caporali et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> reported transient adverse events in 64 of the 502 patients, of whom 57 had transient paresthesias, 8 hematoma, 27 local inflammatory signs, and 5 had others (granuloma, bleeding, and internal scar). Pijpe et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> reported 4 cases of hypoesthesia of the incision site, 2 of which persisted for more than 12 months and 11 cases of pain lasting than 1 month. Moreover, Teppo and Revonta reported a case of pyogenic granuloma.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Patients who underwent MSGB were referred for the study of sicca syndrome by professionals of both our institution and other rheumatology departments who did not have the means for carrying it out. This explains the lack of some data for analysis.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Protection of human and animal subjects</span>. The authors declare that no experiments were performed on humans or animals for this investigation.</p><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Confidentiality of Data</span>. The authors declare that they have followed the protocols of their work centre on the publication of patient data and that all the patients included in the study have received sufficient information and have given their informed consent in writing to participate in that study.</p><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Right to privacy and informed consent</span>. The authors have obtained the informed consent of the patients and /or subjects mentioned in the article. The author for correspondence is in possession of this document.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Disclosure</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no disclosures to make.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres125924" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec113219" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres125923" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Materiales y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec113218" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical Analysis" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Ethical disclosures" ] 10 => array:2 [ "identificador" => "sec0030" "titulo" => "Disclosure" ] 11 => array:2 [ "identificador" => "xack38126" "titulo" => "Acknowledgment" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-10-05" "fechaAceptado" => "2012-03-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec113219" "palabras" => array:3 [ 0 => "Sjögren syndrome" 1 => "Minor salivary gland biopsy" 2 => "Complications" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec113218" "palabras" => array:3 [ 0 => "Síndrome de Sjögren" 1 => "Biopsia de glándulas salivales menores" 2 => "Complicaciones" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Findings of specific antibodies and histopathology data are essential for the diagnosis of Sjögren syndrome (SS). Although the minor salivary gland biopsy (MSGB) is technically simple, it needs to be performed in a medical institution to avoid complications.</p> <span class="elsevierStyleSectionTitle">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To determine the frequency of complications and the usefulness of this technique.</p> <span class="elsevierStyleSectionTitle">Materials and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patients who underwent a minor salivary gland biopsy for a possible diagnosis of SS at Rivadavia Hospital between October 2007 and May 2010 where included. The patients were seen a week and a month after the procedure for follow-up.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Frequency of acute complications (n=186): 15 patients; 8.1%, 95% CI: 4.7–13.2 (Bleeding 7.5%, syncope 3.2%, hematoma 2.7%. No accidents occurred). Medium term complications (n=164): 16 patients: 9.75%, 95% CI: 5.9–15.6 (pain 7.32%, inflammation 3.66%, sensitivity disorders 3.05%, granuloma 1.22%). No infections or suture dehiscence occurred. Microscopic results: 154 biopsy reports were received: glandular 90.9%, 95% CI: 85–95 (typical, sialadenitis, grade III and IV infiltration).</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">MSGB has very low frequency of medium term and acute complications and it has high usefulness.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El hallazgo de anticuerpos específicos y datos histopatológicos son indispensables para llegar al diagnóstico de síndrome de Sjögren (SS). La biopsia de glándulas salivales menores (BGSM), si bien es un procedimiento sencillo, debe ser realizada en una institución a fin de evitar complicaciones.</p> <span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estimar la frecuencia de complicaciones mediatas e inmediatas y el rédito de la técnica.</p> <span class="elsevierStyleSectionTitle">Materiales y métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron los pacientes derivados al Hospital Rivadavia para realización de biopsia, entre octubre del 2007 y mayo del 2010. Los pacientes fueron citados a la semana y al mes del procedimiento para control de la lesión.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Frecuencia de complicaciones inmediatas (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>186): 15 pacientes: 8,1%, IC del 95%, 4,7–13,2 (sangrado 7,5%, lipotimia 3,2%, hematomas 2,7%; no hubo accidentes). Complicaciones mediatas (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>164): 16 pacientes: 9,75%, IC del 95%, 5,9–15,6 (dolor 7,32%, signos inflamatorios 3,66%, trastornos de sensibilidad 3,05%, granuloma 1,22%). No hubo casos de infecciones, ni dehiscencia del punto de sutura. Rédito microscópico: total 154 biopsias: se obtuvo tejido glandular en el 90,9%, IC del 95%, 85–95 (típica, sialoadenitis, infiltrado grado III y IV).</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La BGSM presenta una baja frecuencia de complicaciones mediatas e inmediatas y un alto rédito en el estudio anatomo-patológico.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Lida Santiago M, et al. Frecuencia de complicaciones y rédito de la biopsia de glándula salival menor. Reumatol Clin. 2012. <span class="elsevierStyleInterRef" href="doi:10.1016/j.reuma.2012.03.006">http://dx.doi.org/10.1016/j.reuma.2012.03.006</span>.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">IQR: interquartile range.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Manifestations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Absolute Value/Percentage \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male/female gender \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9/177 (4.8/95.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age, median (year) \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">53 (IQR 45–60) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time since onset of symptoms, median (years) \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">1 (IQR 0.64–3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Xerostomy \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">155 (83.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Xerophtalmia \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">168 (90.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Positive syalometry (n=170) \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 (36.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-Ro positive (n=122) \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">40 (32.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-La positive (n=115) \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">20 (17.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ANA≥1:80 (n=138) \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">91 (65.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rheumatoid factor≥30 (n=109) \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">42 (38.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pylocarpin (n=177) \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">4 (2.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glucocorticoids<20<span class="elsevierStyleHsp" style=""></span>mg prednisone (n=179) \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">25 (13.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hydroxicloroquine \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">27 (14.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immunosuppressants \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">14 (7.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab212432.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Clinical and Serologic Characteristics of Patients Evaluated.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><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">Immediate complications \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (8.1%, 95% CI, 4.7–13.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bleeding \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (7.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fainting \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (3.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hematoma \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (2.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Accident \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mediate complications \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (9.75%, 95% CI, 5.9–15.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pain \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (7.32%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inflammation \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (3.66%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sensitivity abnormalities \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (3.05%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Granuloma \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1.22%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suture dehiscence \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infection \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab212433.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Immediate and Mediate Complications.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The management 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| 2024 April | 52 | 31 | 83 |
| 2024 March | 52 | 29 | 81 |
| 2024 February | 40 | 29 | 69 |
| 2024 January | 51 | 20 | 71 |
| 2023 December | 34 | 23 | 57 |
| 2023 November | 27 | 32 | 59 |
| 2023 October | 50 | 36 | 86 |
| 2023 September | 115 | 36 | 151 |
| 2023 August | 43 | 20 | 63 |
| 2023 July | 41 | 30 | 71 |
| 2023 June | 37 | 29 | 66 |
| 2023 May | 33 | 21 | 54 |
| 2023 April | 34 | 5 | 39 |
| 2023 March | 67 | 36 | 103 |
| 2023 February | 47 | 36 | 83 |
| 2023 January | 49 | 22 | 71 |
| 2022 December | 73 | 39 | 112 |
| 2022 November | 56 | 35 | 91 |
| 2022 October | 86 | 46 | 132 |
| 2022 September | 50 | 45 | 95 |
| 2022 August | 46 | 37 | 83 |
| 2022 July | 39 | 53 | 92 |
| 2022 June | 45 | 45 | 90 |
| 2022 May | 50 | 41 | 91 |
| 2022 April | 71 | 60 | 131 |
| 2022 March | 72 | 53 | 125 |
| 2022 February | 73 | 56 | 129 |
| 2022 January | 50 | 61 | 111 |
| 2021 December | 50 | 47 | 97 |
| 2021 November | 65 | 46 | 111 |
| 2021 October | 107 | 63 | 170 |
| 2021 September | 45 | 50 | 95 |
| 2021 August | 46 | 55 | 101 |
| 2021 July | 44 | 32 | 76 |
| 2021 June | 59 | 37 | 96 |
| 2021 May | 75 | 45 | 120 |
| 2021 April | 155 | 90 | 245 |
| 2021 March | 112 | 35 | 147 |
| 2021 February | 75 | 36 | 111 |
| 2021 January | 92 | 23 | 115 |
| 2020 December | 66 | 41 | 107 |
| 2020 November | 66 | 33 | 99 |
| 2020 October | 45 | 17 | 62 |
| 2020 September | 79 | 28 | 107 |
| 2020 August | 43 | 21 | 64 |
| 2020 July | 39 | 28 | 67 |
| 2020 June | 45 | 35 | 80 |
| 2020 May | 38 | 20 | 58 |
| 2020 April | 40 | 16 | 56 |
| 2020 March | 22 | 12 | 34 |
| 2020 February | 1 | 0 | 1 |
| 2020 January | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 June | 1 | 0 | 1 |
| 2019 March | 1 | 0 | 1 |
| 2019 January | 1 | 0 | 1 |
| 2018 May | 9 | 1 | 10 |
| 2018 April | 33 | 7 | 40 |
| 2018 March | 62 | 8 | 70 |
| 2018 February | 44 | 5 | 49 |
| 2018 January | 32 | 5 | 37 |
| 2017 December | 60 | 6 | 66 |
| 2017 November | 47 | 7 | 54 |
| 2017 October | 58 | 7 | 65 |
| 2017 September | 63 | 13 | 76 |
| 2017 August | 55 | 7 | 62 |
| 2017 July | 74 | 6 | 80 |
| 2017 June | 106 | 4 | 110 |
| 2017 May | 105 | 11 | 116 |
| 2017 April | 84 | 13 | 97 |
| 2017 March | 93 | 7 | 100 |
| 2017 February | 60 | 6 | 66 |
| 2017 January | 63 | 5 | 68 |
| 2016 December | 106 | 9 | 115 |
| 2016 November | 111 | 12 | 123 |
| 2016 October | 120 | 20 | 140 |
| 2016 September | 129 | 4 | 133 |
| 2016 August | 107 | 7 | 114 |
| 2016 July | 64 | 6 | 70 |
| 2016 June | 0 | 11 | 11 |
| 2016 May | 0 | 11 | 11 |
| 2016 April | 1 | 0 | 1 |
| 2016 February | 0 | 16 | 16 |
| 2016 January | 3 | 0 | 3 |
| 2015 December | 2 | 0 | 2 |
| 2015 November | 1 | 0 | 1 |
| 2015 October | 1 | 0 | 1 |
| 2015 September | 1 | 0 | 1 |
| 2015 August | 3 | 0 | 3 |
| 2015 July | 33 | 0 | 33 |
| 2015 June | 66 | 6 | 72 |
| 2015 May | 94 | 11 | 105 |
| 2015 April | 105 | 10 | 115 |
| 2015 March | 103 | 5 | 108 |
| 2015 February | 112 | 7 | 119 |
| 2015 January | 123 | 7 | 130 |
| 2014 December | 93 | 5 | 98 |
| 2014 November | 72 | 11 | 83 |
| 2014 October | 69 | 4 | 73 |
| 2014 September | 66 | 9 | 75 |
| 2014 August | 58 | 10 | 68 |
| 2014 July | 72 | 13 | 85 |
| 2014 June | 65 | 6 | 71 |
| 2014 May | 40 | 11 | 51 |
| 2014 April | 53 | 10 | 63 |
| 2014 March | 52 | 15 | 67 |
| 2014 February | 58 | 19 | 77 |
| 2014 January | 58 | 13 | 71 |
| 2013 December | 41 | 10 | 51 |
| 2013 November | 42 | 11 | 53 |
| 2013 October | 58 | 11 | 69 |
| 2013 September | 48 | 11 | 59 |
| 2013 August | 43 | 10 | 53 |
| 2013 July | 50 | 9 | 59 |
| 2013 June | 54 | 18 | 72 |
| 2013 May | 51 | 16 | 67 |
| 2013 April | 51 | 17 | 68 |
| 2013 March | 44 | 22 | 66 |
| 2013 February | 47 | 15 | 62 |
| 2013 January | 48 | 22 | 70 |
| 2012 December | 37 | 19 | 56 |
| 2012 November | 47 | 28 | 75 |
| 2012 October | 19 | 25 | 44 |
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