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Discriminant Validity Study of Ultrasound Achilles Enthesis
Estudio sobre la validez discriminante de la ecografía de entesis aquílea
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In their article, “The enthesis organ concept and its relevance to the spondyloarthropathies”,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Michael Benjamin and Dennis McGonagle propose this concept and use it to explain their understanding of this “organ”. It is thought to have a biomechanical basis that, in a context of genetic predisposition, triggers an autoinflammatory process that causes the disease affecting the entheseal fibrocartilage.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2–4</span></a> The enthesis organ concept provides an explanation for the connection among bursitis, synovitis and enthesitis.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5,6</span></a> The Achilles tendon has been considered an example of an enthesis organ.</p><p id="par0010" class="elsevierStylePara elsevierViewall">On the other hand, ultrasound is a highly valuable tool in the diagnosis and assessment of the activity of inflammatory diseases. Several studies have validated ultrasound for the evaluation of entheses.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The ultrasound index of Balint et al. (the Glasgow Ultrasound Enthesitis Scoring System [GUESS])<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> rates the Achilles tendon, plantar tendon, distal and proximal patellar ligaments and quadriceps tendon. The Sonographic Enthesitic Index of Alcalde et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> examines the same entheses, but distinguishes between acute and chronic lesions. D‘Agostino et al.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">9,10</span></a> introduced Doppler imaging to assess activity. Hamdi et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> correlated the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES for ultrasound) and a Doppler score with the visual analog scale (VAS) for pain, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI), and the Ankylosing Spondylitis Quality of Life (ASQoL) instrument. Chronic ultrasound lesions did not correlate with any parameter.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In their study, De Miguel et al.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">12,13</span></a> used the Madrid Sonography Enthesitis Index (MASEI) to explore 6 entheses (the 5 mentioned above and a triceps tendon) and 6 variables (including Doppler signal) associated with the elementary lesions. They reported a sensitivity of 83.3% and a specificity of 82.8%. This may be the most sensitive method for evaluating inflammatory lesions and structural damage.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Evaluation of the discriminant validity of enthesis ultrasound has been limited to studies involving mechanical processes, healthy processes and SpA<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> and, in some cases, rheumatoid arthritis (RA) (De Miguel et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a>; D’Agostino et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a>). However, until now, it has not been studied in other enthesopathies, like the microcrystalline diseases, which also affect the entheses.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Thus, the main objective of this study is to compare the discriminant validity of enthesis ultrasound in different models of rheumatic diseases.</p><p id="par0035" class="elsevierStylePara elsevierViewall">On the other hand, the assessment of several entheses is too time-consuming to be easily carried out in routine practice; therefore, to improve the feasibility of this study of the discriminant power of ultrasound, we have focused on the Achilles enthesis, as it is the most representative example of these structures.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and Methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">We performed a cross-sectional, observational, analytical study consisting of 5 arms. The study population was formed by the systematic consecutive recruitment of the first 3 patients to come to a hospital rheumatology department for examination of the lesions to be studied between September and November 2012, provided they consented to being enrolled. They were paired by sex and age. The study was approved by the hospital ethics committees. In addition to demographic data and the Disease Activity Score in 28 Joints (DAS28) for each patient, we recorded the BASDAI and VAS corresponding to the entheses examined.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Each patient underwent ultrasound of the Achilles tendon. The sonographer was blinded to the patient's clinical and diagnostic data. Ninety-seven patients (194 Achilles tendons) were examined and, according to the criteria they met for each disease, were included in 1 of 5 groups: AR (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>20), SpA (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21), gout (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>17), chondrocalcinosis (CC; n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>15) and osteoarthritis (OA; n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>24).</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Ultrasound Examination</span><p id="par0050" class="elsevierStylePara elsevierViewall">The activity and structural damage were assessed by means of the ultrasound examination of 6 elementary lesions of the Achilles tendon. For this purpose, the sonographer underwent training in enthesis ultrasound and a rotation in the unit in which the MASEI had been created, achieving a good overall reliability, according to the kappa statistic and intraclass correlation coefficient.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The findings were scored according to the MASEI for the assessment of the elementary lesions:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0060" class="elsevierStylePara elsevierViewall">Calcifications: none<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0; <5<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1; 5–10<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2, and ossification ><span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">–</span><p id="par0065" class="elsevierStylePara elsevierViewall">Structure and thickness were scored as 0 when absent and 1 when present.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">–</span><p id="par0070" class="elsevierStylePara elsevierViewall">Bursa: present (>2<span class="elsevierStyleHsp" style=""></span>mm)<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1 and absent (<2<span class="elsevierStyleHsp" style=""></span>mm)<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">–</span><p id="par0075" class="elsevierStylePara elsevierViewall">Erosions and Doppler signal: absent<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0 and present<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.</p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">We used a Logiq 5 ultrasound system from General Electric Healthcare, with a 12-MHz linear probe for gray scale images and a 6.6-MHz probe for power Doppler, with a 29-dB gain and a pulse repetition frequency of 0.4<span class="elsevierStyleHsp" style=""></span>kHz.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical Analysis</span><p id="par0085" class="elsevierStylePara elsevierViewall">Analysis of variance (ANOVA) was performed to compare the ultrasound findings in the different subgroups. The values are expressed as the mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation.</p><p id="par0090" class="elsevierStylePara elsevierViewall">For the quantitative comparison between SpA and the other diseases, we used Student's <span class="elsevierStyleItalic">t</span> test for independent samples.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Demographic Data</span><p id="par0095" class="elsevierStylePara elsevierViewall">Of the 97 patients, 49 were men (50.51%) and 48, women (49.48%) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The mean age was 55.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.94 years. There were age-related differences in the numbers of patients with gout, CC and OA, as these diseases develop in older patients.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The mean DAS28 was 3.3 in patients with RA and the BASDAI was 2.93 in those with SpA. The mean VAS score for the entheses was 1.4/10, being ≥2 in the patients with SpA and gout, 1.55 in those with RA and <1 in those with OA and CC.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ultrasound Findings</span><p id="par0105" class="elsevierStylePara elsevierViewall">The highest score on the ultrasound index corresponded to SpA and the lowest to OA. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the scores for the different elementary lesions.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The findings in SpA were compared with those recorded for each of the other 4 groups (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel"><span class="elsevierStyleItalic">1.</span></span><p id="par0115" class="elsevierStylePara elsevierViewall">Spondyloarthritis vs RA: The overall ultrasound values and the value for retrocalcaneal bursitis were significantly higher in SpA. There were no significant differences in calcifications, structure, thickness or Doppler signal. The difference in the values for erosions nearly reached statistical significance.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel"><span class="elsevierStyleItalic">2.</span></span><p id="par0120" class="elsevierStylePara elsevierViewall">Spondyloarthritis vs gout: The only significant difference was recorded for erosions, which were more common in SpA.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel"><span class="elsevierStyleItalic">3.</span></span><p id="par0125" class="elsevierStylePara elsevierViewall">Spondyloarthritis vs CC: The values for structure, thickness, erosions, bursitis and Doppler signal were significantly higher in SpA, as was the overall ultrasound score. The value for calcifications was higher in CC, although the difference did not reach statistical significance.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">4.</span><p id="par0130" class="elsevierStylePara elsevierViewall">Spondyloarthritis vs OA: The values were significantly higher in SpA, with the exception of calcifications.</p></li></ul></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0135" class="elsevierStylePara elsevierViewall">Until now, there had been no real discriminant validity studies of enthesis ultrasound; the studies had been limited to isolated reports involving healthy individuals or inflammatory diseases like RA.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">9,13,14</span></a> However, the entheses are frequently affected in microcrystalline diseases and in long-standing OA. In this respect, our study is original as it demonstrates, for the first time, the power of certain elementary lesions to discriminate among different diseases, and especially that of the MASEI score for Achilles enthesis, as compared to different models of rheumatic disease (autoimmune, degenerative and microcrystalline); this index only lacks discriminant validity in the evaluation of gout, although the score is also lower in the latter case.</p><p id="par0140" class="elsevierStylePara elsevierViewall">We find it interesting that calcifications in the enthesis have no discriminant value, and that they are even slightly more intense in microcrystalline diseases. The presence of a Doppler signal was greater in SpA, but the difference was significant only with respect to CC and OA. Erosions are the most specific lesions for the diagnosis of SpA, showing significant differences with respect to all of the other diseases studied, with the exception of RA. On the other hand, retrocalcaneal bursitis was also more common in SpA, significantly more so than in RA, CC and OA.</p><p id="par0145" class="elsevierStylePara elsevierViewall">A limitation to the study is the more advanced age of patients with microcrystalline diseases (gout and CC), a bias that is difficult to correct because these diseases develop at later ages. However, if this bias were to exist, it would be reflected in a greater frequency of calcific lesions, which would increase their overall incidence and, thus, their power as discriminating factors with respect to SpA. Thus, we consider that the discriminant validity is maintained. On the other hand, the inclusion of only elderly patients with inflammatory diseases would create a selection bias that would reduce the validity of the study, since the differential diagnosis is most important in the initial phases. Another limitation is the failure to carry out a collective study of the images or assess inter-reader agreement, although the criteria and measurements were standardized in the training received by the sonographers.</p><p id="par0150" class="elsevierStylePara elsevierViewall">In conclusion, we present the first study using ultrasound in an enthesis to assess its value in discriminating among different diseases. We found that the incidences of some lesions, such as erosions and bursae, and the presence of Doppler signals differ significantly depending on the underlying disease. The MASEI in Achilles tendon shows a potential ability to differentiate between SpA and the other diseases studied, with the exception of gout. These findings should lead to further studies to confirm the discriminatory power of enthesis ultrasound.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical Disclosures</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of human and animal subjects</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of Interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres824574" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec821053" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres824573" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec821052" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and Methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Ultrasound Examination" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Statistical Analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0025" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Demographic Data" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Ultrasound Findings" ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0045" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of Interest" ] 10 => array:2 [ "identificador" => "xack276514" "titulo" => "Acknowledgments" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-03-14" "fechaAceptado" => "2015-08-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec821053" "palabras" => array:7 [ 0 => "Ultrasound" 1 => "Achilles’ tendon" 2 => "Spondyloarthritis" 3 => "Rheumatoid arthritis" 4 => "Gouty arthritis" 5 => "Chondrocalcinosis" 6 => "Osteoarthritis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec821052" "palabras" => array:7 [ 0 => "Ecografía" 1 => "Tendón de Aquiles" 2 => "Espondiloartritis" 3 => "Artritis reumatoide" 4 => "Artritis gotosa" 5 => "Condrocalcinosis" 6 => "Artrosis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We want to know if the ultrasound examination of the Achilles tendon in spondyloarthritis is different compared to other rheumatic diseases.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We studied 97 patients divided into five groups: rheumatoid arthritis, spondyloarthritis, gout, chondrocalcinosis and osteoarthritis, exploring six elementary lesions in 194 Achilles entheses examined.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In our study the total index ultrasonographic Achilles is higher in spondyloarthritis with significant differences. The worst elementary spondyloarthritis lesions for discriminations against other pathologies were calcification.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This study aims to demonstrate the discriminant validity of Achilles enthesitis observed by ultrasound in spondyloarthritis compared with other rheumatic diseases that may also have ultrasound abnormalities such enthesis level.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar si la exploración ecográfica del tendón de Aquiles es diferente en las espondiloartritis respecto de otras enfermedades reumáticas.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se estudia a 97 pacientes divididos en 5 grupos: artritis reumatoide, espondiloartritis, gota, condrocalcinosis y artrosis, explorándose 6 lesiones elementales en las 194 entesis de Aquiles examinadas.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En nuestro estudio, el índice total ecográfico en tendón de Aquiles es mayor en el grupo de espondiloartritis con diferencias significativas. La lesión elemental que peor discrimina las espondilitis respecto de otras patologías es la presencia de calcificaciones.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Este estudio pretende demostrar la validez discriminante de la entesitis aquílea observada por ecografía en las espondiloartritis en comparación con otras enfermedades reumatológicas que también pueden presentar alteraciones ecográficas a nivel de dicha entesis.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Expósito Molinero MR, de Miguel Mendieta E. Estudio sobre la validez discriminante de la ecografía de entesis aquílea. Reumatol Clin. 2016;12:206–209.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">VAS, visual analog scale.</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"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Achilles tendons (n) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Men (n) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Women (n) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tendon VAS (0–10<span class="elsevierStyleHsp" style=""></span>cm) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ultrasound index (0–12) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rheumatoid arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.75 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spondyloarthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.61 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gout \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.82 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chondrocalcinosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osteoarthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.92 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386296.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Variables Corresponding to Each Study Group.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CC, chondrocalcinosis; GT, gout; M, mean; MASEI, Madrid Sonography Enthesitis Index; OA, osteoarthritis; RA, rheumatoid arthritis; SD, standard deviation; SpA, spondyloarthritis; VAS, visual analog scale.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The data are expressed as the mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation.</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"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">RA</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SpA</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">GT</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CC</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">OA</th><th class="td" title="table-head " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">M \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">M \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">M \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">M \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">M \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.816 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.402 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.978 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.736 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.339 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.007 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calcification \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.940 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.483 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.197 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.737 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.977 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.109 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Structure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.875 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.913 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.795 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.834 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.717 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thickness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.875 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.913 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.795 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.834 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.464 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Erosion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.714 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.191 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.312 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bursa \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.513 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.944 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.935 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.737 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.415 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Doppler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.099 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.309 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.386 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.612 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.045 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Achilles MASEI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.567 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.162 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.261 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.853 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tendon VAS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.849 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.118 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.082 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.717 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386295.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Comparison Among the Study Groups.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The enthesis organ concept and its relevance to the spondyloarthropathies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 14 | 24 |
| 2024 October | 35 | 28 | 63 |
| 2024 September | 35 | 29 | 64 |
| 2024 August | 58 | 43 | 101 |
| 2024 July | 46 | 34 | 80 |
| 2024 June | 41 | 33 | 74 |
| 2024 May | 44 | 25 | 69 |
| 2024 April | 44 | 22 | 66 |
| 2024 March | 47 | 26 | 73 |
| 2024 February | 42 | 28 | 70 |
| 2024 January | 27 | 19 | 46 |
| 2023 December | 21 | 23 | 44 |
| 2023 November | 29 | 20 | 49 |
| 2023 October | 28 | 32 | 60 |
| 2023 September | 60 | 36 | 96 |
| 2023 August | 26 | 15 | 41 |
| 2023 July | 32 | 22 | 54 |
| 2023 June | 28 | 25 | 53 |
| 2023 May | 30 | 17 | 47 |
| 2023 April | 17 | 12 | 29 |
| 2023 March | 39 | 34 | 73 |
| 2023 February | 37 | 23 | 60 |
| 2023 January | 36 | 17 | 53 |
| 2022 December | 42 | 34 | 76 |
| 2022 November | 53 | 27 | 80 |
| 2022 October | 42 | 31 | 73 |
| 2022 September | 27 | 30 | 57 |
| 2022 August | 31 | 51 | 82 |
| 2022 July | 24 | 37 | 61 |
| 2022 June | 29 | 22 | 51 |
| 2022 May | 32 | 46 | 78 |
| 2022 April | 31 | 42 | 73 |
| 2022 March | 34 | 39 | 73 |
| 2022 February | 16 | 25 | 41 |
| 2022 January | 24 | 34 | 58 |
| 2021 December | 27 | 36 | 63 |
| 2021 November | 28 | 44 | 72 |
| 2021 October | 41 | 50 | 91 |
| 2021 September | 28 | 39 | 67 |
| 2021 August | 37 | 49 | 86 |
| 2021 July | 21 | 33 | 54 |
| 2021 June | 34 | 44 | 78 |
| 2021 May | 39 | 61 | 100 |
| 2021 April | 90 | 135 | 225 |
| 2021 March | 71 | 40 | 111 |
| 2021 February | 41 | 34 | 75 |
| 2021 January | 31 | 30 | 61 |
| 2020 December | 44 | 30 | 74 |
| 2020 November | 33 | 26 | 59 |
| 2020 October | 20 | 19 | 39 |
| 2020 September | 43 | 36 | 79 |
| 2020 August | 26 | 28 | 54 |
| 2020 July | 19 | 17 | 36 |
| 2020 June | 28 | 28 | 56 |
| 2020 May | 24 | 11 | 35 |
| 2020 April | 30 | 23 | 53 |
| 2020 March | 12 | 9 | 21 |
| 2020 February | 1 | 0 | 1 |
| 2019 January | 2 | 0 | 2 |
| 2018 May | 6 | 0 | 6 |
| 2018 April | 23 | 7 | 30 |
| 2018 March | 32 | 16 | 48 |
| 2018 February | 25 | 8 | 33 |
| 2018 January | 15 | 5 | 20 |
| 2017 December | 23 | 10 | 33 |
| 2017 November | 24 | 6 | 30 |
| 2017 October | 27 | 6 | 33 |
| 2017 September | 26 | 13 | 39 |
| 2017 August | 26 | 10 | 36 |
| 2017 July | 30 | 12 | 42 |
| 2017 June | 52 | 17 | 69 |
| 2017 May | 49 | 28 | 77 |
| 2017 April | 26 | 10 | 36 |
| 2017 March | 24 | 10 | 34 |
| 2017 February | 17 | 16 | 33 |
| 2017 January | 29 | 11 | 40 |
| 2016 December | 61 | 27 | 88 |
| 2016 November | 40 | 23 | 63 |
| 2016 October | 57 | 26 | 83 |
| 2016 September | 67 | 15 | 82 |
| 2016 August | 111 | 21 | 132 |
| 2016 July | 54 | 23 | 77 |
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