Original breve
Weather conditions may worsen symptoms in rheumatoid arthritis patients: The possible effect of temperature
Influencia de las condiciones climáticas en el empeoramiento de los síntomas de artritis reumatoide: El posible efecto de la temperatura
Lydia Abasoloa, Aurelio Tobíasb, Leticia Leona,c,
, Loreto Carmonac, Jose Luis Fernandez-Ruedaa, Ana Belen Rodriguezd, Benjamin Fernandez-Gutierrezd, Juan Angel Joverd
Corresponding author
a Rheumatology Unit, Fundación para la Investigación Biomédica, Instituto de Investigación Sanitaria, Hospital Clínico San Carlos, Madrid, Spain
b Institute of Environmental Assessment and Water Research (IDAEA), Spanish Council for Scientific Research (CSIC), Barcelona, Spain
c Camilo José Cela University, Madrid, Spain
d Rheumatology Unit, Hospital Clínico San Carlos, Madrid, Spain
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"etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 3 => array:3 [ "nombre" => "Loreto" "apellidos" => "Carmona" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Jose Luis" "apellidos" => "Fernandez-Rueda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Ana Belen" "apellidos" => "Rodriguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 6 => array:3 [ "nombre" => "Benjamin" "apellidos" => "Fernandez-Gutierrez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 7 => array:3 [ "nombre" => "Juan Angel" "apellidos" => "Jover" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Rheumatology Unit, Fundación para la Investigación Biomédica, Instituto de Investigación Sanitaria, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Institute of Environmental Assessment and Water Research (IDAEA), Spanish Council for Scientific Research (CSIC), Barcelona, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Camilo José Cela University, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Rheumatology Unit, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Influencia de las condiciones climáticas en el empeoramiento de los síntomas de artritis reumatoide: El posible efecto de la temperatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1750 "Ancho" => 2389 "Tamanyo" => 194542 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Graphical representation of the non-parametric adjustment of the relationship between daily RA worsening and daily mean temperature, by age group.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with rheumatic conditions often complain that certain meteorological conditions aggravate their disease symptoms.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> However, studies on influence of weather conditions<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3–8</span></a> have reported conflicting results, most related to rheumatoid arthritis patients (RA). Some studies indicated that weather conditions do not influence the symptoms of arthritis,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> whereas others found an influence related to low temperature, high atmospheric pressure, and high humidity.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4,9</span></a> Moreover, some authors found a seasonal effect<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> but others did not.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8</span></a> Thus, scientific evidence on the effects of atmospheric factors on rheumatic diseases is sparse and non-conclusive. Discrepancies could be related to the diverse climatic conditions from each geographic area studied and also due to the different methodologies used.</p><p id="par0010" class="elsevierStylePara elsevierViewall">To our knowledge no study has previously been conducted in our setting for these rheumatic disorders. Our objective is to investigate the short-term effects of weather conditions on the acute worsening in rheumatic patients due to RA related conditions and also to determine possible seasonal fluctuations.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">This study was conducted in the city of Madrid, Spain, with a Mediterranean continental climate very influenced by urban conditions. Winters are cold, with mean temperatures below 10<span class="elsevierStyleHsp" style=""></span>°C with frequent frosts at night and occasional snowfalls. Summers are warm with mean temperatures over 20<span class="elsevierStyleHsp" style=""></span>°C.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Daily cases of RA worsening, were defined as those patients who come to the emergency room, were attended by a rheumatologist of Hospital Clínico San Carlos, and were diagnosed with RA as the main cause reflected in the ICD code (10th revision), from 1st January 2004 until 31st December 2007. The Hospital Clínico San Carlos is a tertiary hospital, covering a population over 500,000 inhabitants. For all cases we also collected age, gender, and disability index.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The study was approved by the HCSC Ethics Committee.</p><p id="par0030" class="elsevierStylePara elsevierViewall">As weather conditions we measured: Daily mean, maximum and minimum temperatures (in °C), relative humidity (%), pressure (hPA), rain (mm), hours of sun, and cloud cover (octas) were obtained from the European Climate Assessment & Dataset (ECA&D).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The association of weather conditions with daily RA worsening was investigated using a case-crossover design,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> which uses the day on which the RA aggravation occurs as a case day. Exposure on case days is compared with exposure on days on which the RA worsening does not occur (control days). A time-stratified approach was selecting control days from the same day of the week, month, and year as case days. This minimise bias from time-trends and other time-varying confounders.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Short-term effects of weather variables on daily cases, from the same day up to one-week lag, were estimated using conditional logistic regression.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 245 patients with 306 RA visits to the emergency room due to RA as the main diagnostic reason during the study period were included. Most were women (71%), with a mean age of 63.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.4 years. Two thirds were attended at least twice in the emergency room due to RA worsening, with some level of disability (90% with a Rosser index less than 0.990). During the study period weather conditions were on average: 14.6<span class="elsevierStyleHsp" style=""></span>°C of temperature (ranging from −5 to 39), 54% of relative humidity (15–96), 1.018<span class="elsevierStyleHsp" style=""></span>hPA of pressure (904–1408), 111<span class="elsevierStyleHsp" style=""></span>mm of rain (0–420), 8.3<span class="elsevierStyleHsp" style=""></span>h of sun (1–14), and 3.2 octas of cloud cover (0–8).</p><p id="par0045" class="elsevierStylePara elsevierViewall">Statistical significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) association with RA worsening was only found for daily mean temperature, with a lagged effect of 1 day, in middle age patients from 50 to 65 years old (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). These were 16% more likely to present symptomatic deterioration of RA, with lower mean temperature (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.86, 95% CI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>[0.78–0.96] for an increase of 1<span class="elsevierStyleHsp" style=""></span>°C). Both, men and women, showed similar risk estimates with mean temperature. No other weather conditions were statistically associated with the need of RA patients to bee attended in the emergency room due to RA related conditions.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">To evaluate seasonal variations mean temperature was fitted in the conditional logistic regression model using a cubic spline, with 3 degrees of freedom (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Significant effects were only found in the most extreme ranges of mean temperature for middle age people, being 15% and 20% more likely of RA worsening with mean temperatures below 10<span class="elsevierStyleHsp" style=""></span>°C (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.83, 95% CI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>[0.69–0.99]) and above 20<span class="elsevierStyleHsp" style=""></span>°C (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.82, 95% CI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>[0.66–0.99]).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">There is a popular belief that rheumatic conditions are particularly sensitive to fluctuations of weather. We have found associations with meteorological conditions (specifically with temperature), and RA related problems in the subgroup of middle age patients.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The failure to find associations with other age groups could be explained because age itself is a risk factor for disability, thus elderly could have in general more difficulty to go to the emergency room by themselves. Moreover, rheumatic pain is frequently considered to be a natural part of the aging process. Otherwise, the younger may have problems to miss work using other ways rather than emergency room to control their RA symptoms.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Previous studies in similar settings have also found that mean temperature is related with rheumatic disorders.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4,9</span></a> Nevertheless, we did not find associations with other weather variables, as atmospheric pressure or relative humidity, probably due to Madrid has a Mediterranean continental climate much dryer and less humid than other cities studied.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4,9</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">We found that the strongest effects of daily mean temperature on RA worsening were found below 10<span class="elsevierStyleHsp" style=""></span>°C and above 20<span class="elsevierStyleHsp" style=""></span>°C, meanwhile no statistical association was observed between 10 and 20<span class="elsevierStyleHsp" style=""></span>°C. This could reflect the possible seasonal distribution of RA symptomatic deterioration with higher incidence in winter and summer. Additionally, between 10 and 20<span class="elsevierStyleHsp" style=""></span>°C the thermal sensation and small changes probably are better tolerated than in the others, where we subjectively feel cooler or warmer.</p><p id="par0075" class="elsevierStylePara elsevierViewall">It is important to note that in our setting, RA patients receive long-term monitoring, with self-education in the management of pain and small flares. They are encourage to contact us when they have some kind of medical problem, either by telephone or by medical appointments in 24–48<span class="elsevierStyleHsp" style=""></span>h. When they have the need to go to the emergency room is often a due to a disabling pain or significant inflammatory activity. With the data available we cannot specify the main cause of RA symptomatic deterioration.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The main contribution of our study is the methodological approach using a case-crossover design, a common study design to assess for short-term effects of environmental factors on health.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> Moreover, our RA patients were well represented, 70% women in their sixties.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The explanation of the influence of temperature on rheumatic diseases is not clear enough. It is known that cold unleash some diseases such as Raynaud phenomenon or crioglobulinemia, both closely related to rheumatic diseases. Maybe muscles also play a role in relation to flares or pain in RA patients and cold weather, due to coldness stiffens muscles around the joints, and this might worsen the arthritis symptoms.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In conclusion, our results support that weather conditions, essentially daily mean temperature, may be influencing in RA patients.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical considerations</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Protection of human and animal subjects</span>. The authors declare that the procedures followed were in accordance with the regulations of the responsible Clinical Research Ethics Committee and in accordance with those of the World Medical Association and the Helsinki Declaration.<span class="elsevierStyleVsp" style="height:0.5px"></span><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.<span class="elsevierStyleVsp" style="height:0.5px"></span><span class="elsevierStyleBold">Right to privacy and informed consent</span>. The authors declare that no patient data appears in this article.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">Authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres222857" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec208314" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres222858" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec208313" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Ethical considerations" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-05-29" "fechaAceptado" => "2012-09-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec208314" "palabras" => array:3 [ 0 => "Weather conditions" 1 => "Rheumatoid arthritis" 2 => "Temperature" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec208313" "palabras" => array:3 [ 0 => "Condiciones meteorológicas" 1 => "Artritis reumatoide" 2 => "Temperatura" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patients with rheumatoid arthritis (RA) complain that weather conditions aggravate their symptoms. We investigated the short-term effects of weather conditions on worsening of RA and determined possible seasonal fluctuations.</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We conducted a case-crossover study in Madrid, Spain. Daily cases of RA flares were collected from the emergency room of a tertiary level hospital between 2004 and 2007.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">245 RA patients who visited the emergency room 306 times due to RA related complaints as the main diagnostic reason were included in the study. Patients from 50 to 65 years old were 16% more likely to present a flare with lower mean temperatures.</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Our results support the belief that weather influences rheumatic pain in middle aged patients.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los pacientes con artritis reumatoide (AR) se quejan de que las condiciones meteorológicas empeoran sus síntomas. Este estudio trata de ver los efectos a corto plazo de las condiciones climáticas en empeoramiento sintomático en pacientes con AR y determinar posibles fluctuaciones estacionales.</p> <span class="elsevierStyleSectionTitle">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realizó un estudio de casos cruzados en Madrid, España. Los casos diarios de empeoramiento de la AR se obtuvieron de la sala de urgencias de un hospital terciario entre 2004 y 2007.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">245 pacientes con AR con 306 visitas a urgencias con AR como diagnostico principal se incluyeron en el estudio. Los pacientes de 50 a 65 años tuvieron un 16% más de probabilidades de presentar empeoramiento sintomático de la AR con una menor temperatura media.</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nuestros resultados apoyan la creencia de que el clima influye en el dolor reumático de los pacientes con mediana edad.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1750 "Ancho" => 2389 "Tamanyo" => 194542 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Graphical representation of the non-parametric adjustment of the relationship between daily RA worsening and daily mean temperature, by age group.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \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"><span class="elsevierStyleItalic">n</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a> \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">(%) \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">OR \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">95% CI \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"><span class="elsevierStyleItalic">p</span> \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 " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Age group</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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"><span class="elsevierStyleHsp" style=""></span><50 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 \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">(20.0) \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">0.999 \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">(0.909–1.098) \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">0.986 \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"><span class="elsevierStyleHsp" style=""></span>50–65 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73 \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">(23.5) \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">0.868 \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">(0.783–0.962) \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">0.007 \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"><span class="elsevierStyleHsp" style=""></span>>65 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">173 \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">(56.5) \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">1.035 \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">(0.979–1.095) \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">0.223 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Total</span> \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">306 \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">(100) \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">0.993 \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">(0.952–1.037) \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">0.776 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab337035.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara">Number of AR cases.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Odds ratio (OR), and 95% confidence interval (95% CI), of daily RA worsening for an increase of 1<span class="elsevierStyleHsp" style=""></span>°C of daily mean temperature (for a 1-day lag), by age group.</p>" ] ] ] "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" => "Weather effects in rheumatoid arthritis: from controversy to consensus. A review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "W.R. Patberg" 1 => "J.J. Rasker" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Rheumatol" "fecha" => "2004" "volumen" => "31" "paginaInicial" => "1327" "paginaFinal" => "1334" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15229951" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Does the weather really matter? A cohort study of influences of weather and solar conditions on daily variations of joint pain in patients with rheumatoid arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Smedslund" 1 => "P. Mowinckel" 2 => "T. Heiberg" 3 => "T.K. Kvien" 4 => "K.B. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 17 | 25 |
| 2024 October | 60 | 31 | 91 |
| 2024 September | 69 | 15 | 84 |
| 2024 August | 61 | 27 | 88 |
| 2024 July | 65 | 34 | 99 |
| 2024 June | 66 | 35 | 101 |
| 2024 May | 67 | 26 | 93 |
| 2024 April | 33 | 15 | 48 |
| 2024 March | 39 | 20 | 59 |
| 2024 February | 30 | 19 | 49 |
| 2024 January | 38 | 26 | 64 |
| 2023 December | 28 | 27 | 55 |
| 2023 November | 40 | 49 | 89 |
| 2023 October | 21 | 36 | 57 |
| 2023 September | 79 | 46 | 125 |
| 2023 August | 21 | 16 | 37 |
| 2023 July | 31 | 28 | 59 |
| 2023 June | 44 | 18 | 62 |
| 2023 May | 45 | 24 | 69 |
| 2023 April | 16 | 10 | 26 |
| 2023 March | 36 | 29 | 65 |
| 2023 February | 25 | 26 | 51 |
| 2023 January | 37 | 33 | 70 |
| 2022 December | 36 | 35 | 71 |
| 2022 November | 47 | 26 | 73 |
| 2022 October | 47 | 32 | 79 |
| 2022 September | 28 | 50 | 78 |
| 2022 August | 28 | 34 | 62 |
| 2022 July | 29 | 38 | 67 |
| 2022 June | 27 | 28 | 55 |
| 2022 May | 31 | 37 | 68 |
| 2022 April | 29 | 41 | 70 |
| 2022 March | 36 | 47 | 83 |
| 2022 February | 22 | 28 | 50 |
| 2022 January | 25 | 35 | 60 |
| 2021 December | 26 | 41 | 67 |
| 2021 November | 29 | 45 | 74 |
| 2021 October | 40 | 41 | 81 |
| 2021 September | 28 | 29 | 57 |
| 2021 August | 25 | 37 | 62 |
| 2021 July | 22 | 28 | 50 |
| 2021 June | 32 | 28 | 60 |
| 2021 May | 30 | 24 | 54 |
| 2021 April | 36 | 70 | 106 |
| 2021 March | 39 | 17 | 56 |
| 2021 February | 27 | 22 | 49 |
| 2021 January | 17 | 19 | 36 |
| 2020 December | 22 | 14 | 36 |
| 2020 November | 22 | 11 | 33 |
| 2020 October | 16 | 6 | 22 |
| 2020 September | 36 | 21 | 57 |
| 2020 August | 26 | 11 | 37 |
| 2020 July | 20 | 11 | 31 |
| 2020 June | 30 | 11 | 41 |
| 2020 May | 31 | 11 | 42 |
| 2020 April | 20 | 19 | 39 |
| 2020 March | 9 | 9 | 18 |
| 2020 February | 2 | 0 | 2 |
| 2020 January | 3 | 0 | 3 |
| 2019 September | 2 | 0 | 2 |
| 2019 June | 1 | 0 | 1 |
| 2019 April | 2 | 0 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 May | 1 | 0 | 1 |
| 2018 April | 31 | 10 | 41 |
| 2018 March | 32 | 15 | 47 |
| 2018 February | 22 | 8 | 30 |
| 2018 January | 37 | 12 | 49 |
| 2017 December | 33 | 6 | 39 |
| 2017 November | 34 | 13 | 47 |
| 2017 October | 18 | 14 | 32 |
| 2017 September | 32 | 9 | 41 |
| 2017 August | 57 | 10 | 67 |
| 2017 July | 49 | 9 | 58 |
| 2017 June | 79 | 11 | 90 |
| 2017 May | 65 | 9 | 74 |
| 2017 April | 64 | 8 | 72 |
| 2017 March | 47 | 50 | 97 |
| 2017 February | 38 | 8 | 46 |
| 2017 January | 31 | 7 | 38 |
| 2016 December | 53 | 23 | 76 |
| 2016 November | 60 | 9 | 69 |
| 2016 October | 65 | 11 | 76 |
| 2016 September | 58 | 9 | 67 |
| 2016 August | 64 | 5 | 69 |
| 2016 July | 32 | 6 | 38 |
| 2016 June | 1 | 12 | 13 |
| 2016 May | 4 | 0 | 4 |
| 2016 January | 2 | 0 | 2 |
| 2015 December | 5 | 0 | 5 |
| 2015 November | 0 | 14 | 14 |
| 2015 October | 2 | 0 | 2 |
| 2015 September | 2 | 14 | 16 |
| 2015 August | 1 | 0 | 1 |
| 2015 July | 22 | 5 | 27 |
| 2015 June | 39 | 9 | 48 |
| 2015 May | 60 | 19 | 79 |
| 2015 April | 42 | 12 | 54 |
| 2015 March | 38 | 7 | 45 |
| 2015 February | 38 | 12 | 50 |
| 2015 January | 37 | 12 | 49 |
| 2014 December | 47 | 15 | 62 |
| 2014 November | 41 | 13 | 54 |
| 2014 October | 46 | 12 | 58 |
| 2014 September | 44 | 9 | 53 |
| 2014 August | 30 | 18 | 48 |
| 2014 July | 24 | 15 | 39 |
| 2014 June | 56 | 22 | 78 |
| 2014 May | 40 | 28 | 68 |
| 2014 April | 50 | 12 | 62 |
| 2014 March | 40 | 31 | 71 |
| 2014 February | 31 | 24 | 55 |
| 2014 January | 70 | 28 | 98 |
| 2013 December | 31 | 15 | 46 |
| 2013 November | 32 | 16 | 48 |
| 2013 October | 63 | 27 | 90 |
| 2013 September | 43 | 43 | 86 |
| 2013 August | 63 | 53 | 116 |
| 2013 July | 23 | 34 | 57 |
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