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Knowledge on Fibromyalgia Among General Practitioners, From Chiclayo-Peru, 2016
Conocimientos de fibromialgia en médicos de atención primaria de la provincia de Chiclayo-Perú, 2016
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The dark blue ovals indicate the enzymes studied in the present report. The red lines point to the enzymes that are inhibited by methotrexate polyglutamates. ABCB1, transporter that bonds ATP B1; ADA, adenosine deaminase; ADP, adenosine diphosphate; AMP, adenosine monophosphate; ATIC, AICAR transformylase/IMP cyclohydrolase; ATP, adenosine triphosphate; DHFR, dihydrofolate reductase; FPGS, folyl-polyglutamate synthetase; GGH, gamma-glutamyl hydrolase; IMP, inositol monophosphate; MTHFD1, 5,10-methylenetetrahydrofolate dehydrogenase 1; MTHFR, methylenetetrahydrofolate reductase; MTR, methionine reductase; MTX, methotrexate; MTXPG, methotrexate polyglutamates; RFC, reduced folate carrier; SAM, S-adenosyl-1-methionine; TYMS, thymidylate synthetase.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Luis Sala-Icardo, Amalia Lamana, Ana María Ortiz, Elena García Lorenzo, Pablo Moreno Fresneda, Rosario García-Vicuña, Isidoro González-Álvaro" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Luis" "apellidos" => "Sala-Icardo" ] 1 => array:2 [ "nombre" => "Amalia" "apellidos" => "Lamana" ] 2 => array:2 [ "nombre" => "Ana María" "apellidos" => "Ortiz" ] 3 => array:2 [ "nombre" => "Elena" "apellidos" => "García Lorenzo" ] 4 => array:2 [ "nombre" => "Pablo" "apellidos" => "Moreno Fresneda" ] 5 => array:2 [ "nombre" => "Rosario" "apellidos" => "García-Vicuña" ] 6 => array:2 [ "nombre" => "Isidoro" "apellidos" => "González-Álvaro" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1699258X16301012" "doi" => "10.1016/j.reuma.2016.08.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X16301012?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357431730120X?idApp=UINPBA00004M" "url" => "/21735743/0000001300000006/v1_201710250854/S217357431730120X/v1_201710250854/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Knowledge on Fibromyalgia Among General Practitioners, From Chiclayo-Peru, 2016" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "326" "paginaFinal" => "330" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Fátima Evelin Acuña Ortiz, Victoria Alejandra Capitán de la Cruz, Franco Ernesto León Jiménez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Fátima Evelin" "apellidos" => "Acuña Ortiz" "email" => array:1 [ 0 => "evly_22@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Victoria Alejandra" "apellidos" => "Capitán de la Cruz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Franco Ernesto" "apellidos" => "León Jiménez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Facultad de Medicina, Universidad Católica Santo Toribio de Mogrovejo, Chiclayo, Peru" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Regional Lambayeque, Chiclayo, Peru" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Conocimientos de fibromialgia en médicos de atención primaria de la provincia de Chiclayo-Perú, 2016" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fibromyalgia is a disorder with multiple etiologies,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> which is frequently observed in the general population<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> and in outpatient clinics.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> Its coexistence with mental health problems and the changes in the quality of life that it produces makes its early detection crucial. The diagnostic is eminently clinical, there being no ancillary test to determine whether the disease is or is not present.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Regrettably, as occurs with a number of conditions, its diagnosis comes late, often because its presence is not suspected. An extensive medical history and a detailed clinical examination can point to the diagnosis. The diagnostic criteria were established in 1990 by the American College of Rheumatology (ACR).<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The worldwide prevalence is 0.5%–5%.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> In Chiclayo, Peru, the prevalence is 4.25%<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> and in Lambayeque district, it is 2.9%.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> The frequency in the internal medicine outpatient clinic is 9.4%.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The majority of the patients are diagnosed by rheumatologists.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> This prolongs the time to diagnosis. In 2010, Choy et al. reported a study performed in 8 countries that found that patients with fibromyalgia had been evaluated by 3.7 physicians before being diagnosed; the diagnosis is obtained approximately 2.3 years after the onset of symptoms, and that period can range from months to 23 years.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8,9</span></a> Given its high prevalence and importance, its presence should be suspected by primary care physicians.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In Spain, the prevalence of fibromyalgia is 5%–7% in general medicine clinics; approximately 2 or 3 patients can go unnoticed per department.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Perrot et al. conducted a study in 8 countries in 2012 and found that 61% of primary care physicians reported having difficulties with the diagnosis, 45% had very little training in fibromyalgia and 34% considered that they were not knowledgeable about the condition.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Kamoun et al.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> in 2010 and, in France, Túnez and Blotman et al.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> in 2005 reported that 54% and 25%, respectively, of primary care physicians were aware of the identification of the tender points for the diagnosis.</p><p id="par0035" class="elsevierStylePara elsevierViewall">With regard to treatment, physicians recommended physical exercise, swimming, regular walking and biking.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> Other studies mention the use of painkillers and antidepressants as drug therapy.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> In the available studies, most authors reported that they had not received training as undergraduates.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">7,11,12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In 2012, Pastor et al. found that the conception of fibromyalgia on the part of primary care physicians in Spain was that it was important, that it was poorly controlled and was associated with psychological disorders.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> In Canada, Hayes et al. observed that 23% of the general practitioners considered fibromyalgia patients to be “malingerers”, in comparison with 12% of the rheumatologists.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In the province of Chiclayo, we found no information concerning knowledge of the diagnosis and treatment of fibromyalgia in primary care. The reason for performing this study is the present situation of this disease, and because it is a problem with a growing trend in terms of morbidity. The objective was to describe the knowledge of fibromyalgia of the primary care physicians of Chiclayo-Lambayeque in 2016.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and Methods</span><p id="par0050" class="elsevierStylePara elsevierViewall">We conducted a cross-sectional descriptive study. The population was the primary care physicians of Chiclayo in 2016. The sample was non-probabilistic and censal-like; we contacted 145 primary care physicians from the province of Chiclayo practicing under the Ministry of Health (MINSA) or the Social Health Insurance system (EsSalud).</p><p id="par0055" class="elsevierStylePara elsevierViewall">Setting: the province of Chiclayo is in the department of Lambayeque, in northern Peru. Its population is 857,405, 52.9% women and 47.08% men; in 2012, 28.9% were under 15 years of age, 63.2% were between 15 and 64 years old and 8.0% were 65 years old or more. These data correspond to the entire department of Lambayeque. The distribution in the province of Chiclayo is very similar.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In Peru, the health system is composed of the public sector (MINSA, EsSalud, and the armed forces) and the private sector. The MINSA and EsSalud are administrators of the health sector with the greatest representation on the national level (92% of the hospitals, 69% of the health centers and 99% of the positions in health care). Given their representativeness and the feasibility of the study, we considered only physicians of MINSA and EsSalud. In MINSA, the patients attended to are in poverty or extreme poverty, whereas in EsSalud, the patients have a higher socioeconomic level and have worked all their lives. The first contact of the patient is with a primary care physician and, later, if it is warranted, he or she will be referred to a specialist. However, a substantial percentage of patients go directly to a specialist.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">We drafted a questionnaire of 14 multiple choice questions with a single correct alternative, based on a review of the literature and on the 1990 ACR criteria for fibromyalgia, to evaluate issues concerning the diagnosis (10 questions) and treatment (4 questions). The validity of the content was assessed by 4 rheumatologists, who evaluated the appropriateness and intelligibility of each item using a Likert scale in which “1” indicated being “totally in disagreement” and “5” was “totally in agreement”, and obtained an average of 4. A pilot test was performed with 15 internal medicine residents from Chiclayo, and there were no problems with the wording. The average duration of completing the questionnaire was 15<span class="elsevierStyleHsp" style=""></span>minutes. The questionnaire included the illustration of the human body to evaluate the 18 tender points.</p><p id="par0070" class="elsevierStylePara elsevierViewall">We performed a univariate analysis to calculate the central tendency measures, dispersion for numerical variables and frequencies, and percentages for categorical variables. An exploratory analysis was carried out to evaluate the association between the responses to the questions and the sociodemographic variables. The analysis of the data was done using STATA 13 and Excel 2010.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The study was approved by the research ethics committee of the Faculty of Human Medicine at the Universidad Católica Santo Toribio de Mogrovejo. To guarantee the confidentiality of the participants, they were given an informed consent form that explained the objectives of the study. The physicians were given an informative leaflet related to the topics of treatment and diagnosis in fibromyalgia.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">We approached a total of 172 physicians; 14 (8.5%) refused to respond and 13 (7.5%) could not be found. Finally, 145 (84%) agreed to do the questionnaire; 78 (53.7%) were from MINSA and 67 (46.2%) came from EsSalud. All of those who participated were general practitioners, there being none from the specialty of family medicine. The questionnaire was completed once patient visits had ended.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The mean age was 39.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11.1 years, the median was 38 and the range was 24–67 years; 100 (68.9%) were men. The mean age of the men was 41.2<span class="elsevierStyleHsp" style=""></span>±11.7 years and of the women was 37.03<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.5 years. The men were older than the women (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>.004).</p><p id="par0090" class="elsevierStylePara elsevierViewall">The mean number of years since they had graduated was 12.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.7, the median was 10 and the range was 1–36 years.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Other characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">With respect to the questionnaire, the average number of correct replies in diagnostics was 41.1% and in the questions on treatment was 65%.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The overall distribution of correct replies on the questionnaire is summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The physicians who mentioned that “they had heard about fibromyalgia” numbered 142 (97.9%), and 109 (75.1%) responded that “they had seen patients with fibromyalgia”.</p><p id="par0115" class="elsevierStylePara elsevierViewall">With respect to the diagnostic criteria, 24 (48.9%) and 31 (39.3%) physicians younger and older than 35 years responded correctly (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.005). The years since the physicians who responded correctly to this question had graduated was 13.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.6, and was 10.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.6 in those who gave an incorrect reply (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.058). Of the 109 physicians who mentioned that they had seen patients with fibromyalgia, only 38 (34.9%) responded correctly to the question on diagnostic criteria, with no sex-related difference (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.1), but there was a difference between the health institutions: MINSA with 46.1% and EsSalud with 28.3% (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.021).</p><p id="par0120" class="elsevierStylePara elsevierViewall">For the total of the questions, there was no statistically significant difference in the knowledge of men and women. The average of the number of tender points positioned correctly was 2.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.8 and the median was 2. Those under the age of 35 years located more tender points on the human figure (average of points was 2.8; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.02); 56 (38.8%) physicians could not locate any tender points and only 4 (2.8%) positioned 11 or more points correctly. There was a difference in the number of tender points correctly identified depending on the health institution: 3.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.2 in MINSA and 1.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.6 in EsSalud (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001).</p><p id="par0125" class="elsevierStylePara elsevierViewall">In all, 79 (54.4%) responded that “the diagnosis is eminently clinical and the tests are for the differential diagnosis,” 46.1% in MINSA and 64.1% in EsSalud (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.022).</p><p id="par0130" class="elsevierStylePara elsevierViewall">With respect to the most efficient therapeutic triad, 94 (65.7%) responded that it was psychotherapy, pregabalin and aerobic exercise, and 22 (15.4%) responded that it was psychotherapy, paracetamol and anaerobic exercise; 69.7% of those older than 35 years responded correctly to this question (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.059), and there were no differences between MINSA and EsSalud: 61.5% and 68.6%, respectively (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.23); 59.3% responded correctly to the question on the drugs with demonstrated utility: pregabalin, duloxetine and amitriptyline; 66.2% responded that the most effective physical therapy was aerobic exercise and 69.7% responded that the ideal multidisciplinary team for integrated care of the patient would be a rheumatologist, a psychologist and a physical therapist.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0135" class="elsevierStylePara elsevierViewall">This is the first study on knowledge of fibromyalgia involving primary care physicians in Peru. With respect to the diagnosis, we found that only 4 (2.8%) physicians correctly positioned at least 11 tender points for the diagnosis (ACR 1990). In 2010, Kamoun et al., in a cross-sectional study carried out in Tunisia in 440 general practitioners, observed that 54% reported that they knew the location of the points<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> and Blotman et al., in 2005, in France, found that 25% of the physicians surveyed knew the number of tender points.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> However, in those studies, the authors did not evaluate the knowledge of the location of the points. That datum is merely referential. Those results could be explained by unawareness of the existence of the disease, despite the fact that 75.1% of those who completed the questionnaire mentioned that they had seen patients with this condition. Another possibility is the difficulty involved in the anatomic location of the points, which could improve if training of this aspect were practical (in patients). The reality of this topic is unfamiliar to undergraduates in Lambayeque. In international studies, primary care physicians comment that their training in fibromyalgia was inadequate—54% in the study of Perrot et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a>—or they had not had any training.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11,12</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Moreover, the time allotted for outpatient clinics is too short to diagnose a disease of this type. According to the study of Perrot et al., 79% of those surveyed expressed this opinion.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">It was also found that, of all the physicians who had seen fibromyalgia patients, only 34.8% were acquainted with the 1990 ACR diagnostic criteria. A number of studies deal with knowledge of the diagnostic criteria; the range goes from 14% to 59%.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">7,11,12,14</span></a> Perrot et al. conducted a survey of 1622 physicians (among them, 809 general practitioners) in 8 countries (6 European, Mexico and South Korea) that showed that 53% reported difficulties with the diagnosis and that only 40% were knowledgeable about the criteria.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In our study, we found that 55.8% were unfamiliar with conditions that were similar to fibromyalgia; it was considered that the differential diagnosis should include hypothyroidism, major depression and chronic fatigue syndrome. Perrot et al. observed that 90% referred to this matter. Differences in undergraduate training could explain these findings.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Only 31.7% of those participating recognized that insomnia in the second half of the night was common in these individuals. In 2013, in patients from Chiclayo, the rate of insomnia was 80%, and the feeling of non-refreshing sleep was the most widespread type of insomnia (84.6%).</p><p id="par0160" class="elsevierStylePara elsevierViewall">A number of studies report that primary care physicians find it difficult to distinguish between depression and fibromyalgia.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> The symptoms are similar and frequently coexist. In a local study, it was found that 96.2% of the fibromyalgia patients had some level of depression, which was severe in 38.4%.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">With respect to treatment, it is noticeable that more than half of the questions to which correct responses were provided (65%), dealt with treatment rather than the diagnosis (41.1%). This result differs from those of other studies.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">12,14</span></a> In Iran, Kianmehr et al. observed that 52.1% of the physicians indicated that nonsteroidal anti-inflammatory drugs were an option for treatment.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> In our study, the use of nonsteroidal anti-inflammatory agents was evaluated among multiple alternatives, and we are unable to determine the proportion.</p><p id="par0170" class="elsevierStylePara elsevierViewall">The majority of the physicians (69.7%) responded that the patients should be treated by a multidisciplinary team: psychologist, physical therapist and rheumatologist. Fibromyalgia is a disease in which collaborative management is fundamental for the success of the therapy. However, in this question, all of the response options included several professionals and, thus, this datum should be taken with caution. Kamoun et al.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> and Blotman et al.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> found that 40.2% and 54.6% of the physicians referred the patients to a rheumatologist. While it is true that it would be ideal that primary care professionals recognized fibromyalgia, the management of patients who are refractory to treatment or have several comorbidities is competence of a specialist.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Correct responses to the questions on tender points and diagnostic criteria were provided more frequently by physicians under 35 years of age. This probably reflects knowledge recently acquired in rotations through specialties of hospitals of greater complexity or more frequent contact with clinical practice guidelines; however, more often, professionals over the age of 35 responded correctly to the question on aerobic exercise, the use of pregabalin and the need for psychotherapy. This could be due to experience. We found no studies reporting similar findings. The years elapsed after graduation are not associated with a greater knowledge, an outcome that is similar to that observed in a 2015 publication by Kianmehr et al. in Iran.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">When the physicians from MINSA were compared with those from EsSalud, a greater number of the former had recognized the diagnostic criteria and the position of the tender points. However, the latter responded more frequently that the diagnosis was clinical and mentioned the need for aerobic exercise, the use of pregabalin and the need for psychotherapy as an alternative to the management. We found no studies that evaluated the relationship between the health agencies and the level of knowledge. This result might be useful for allocating resources for training medical personnel on the part of the institutions.</p><p id="par0185" class="elsevierStylePara elsevierViewall">In this study, we considered the 1990 ACR criteria.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> However, the ACR issued new diagnostic criteria in 2010.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> Published works measure knowledge in terms of those of 1990. They are still applicable. The use of the new criteria in primary care has not been assessed by means of prospective studies; they include common symptoms and disregard the physical examination. While the diagnosis is mainly based on subjective parameters that are widely accepted in clinical practice, the utilization of the new criteria entails the risk of omitting significant findings detected in the clinical examination that could suggest alternative diagnoses.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> Nevertheless, we must recognize that applying the 1990 ACR criteria is more difficult in outpatient clinics.</p><p id="par0190" class="elsevierStylePara elsevierViewall">We should emphasize that each physician was personally evaluated using a structured knowledge questionnaire, in comparison with other studies involving a self-administered questionnaire based on a score that made it impossible to verify the data.</p><p id="par0195" class="elsevierStylePara elsevierViewall">A number of local studies refer to the inadequacy of the knowledge about diseases that are widespread in the population.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> This might reflect problems in undergraduate training that should be evaluated by the universities and the medical association. It is important to adapt continuing medical education and training of health professionals to the national and regional necessities of medical education. Moreover, it is important that education programs concur with the epidemiological reality of the country, as well as health policies and national programs.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall">Primary care physicians in Chiclayo have an inadequate knowledge of the diagnosis and treatment of fibromyalgia.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Younger physicians and those of MINSA were more familiar with the diagnostic criteria and tender points.</p><p id="par0210" class="elsevierStylePara elsevierViewall">The question about the most effective triad for treatment was answered correctly by a larger number of the older physicians and those of EsSalud.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical Disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of human and animal subjects</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of Interest</span><p id="par0230" 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" => "xres930891" "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" => "xpalclavsec905639" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres930890" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec905638" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of Interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-06-10" "fechaAceptado" => "2016-08-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec905639" "palabras" => array:3 [ 0 => "Fibromyalgia" 1 => "Primary care physicians" 2 => "Knowledge" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec905638" "palabras" => array:3 [ 0 => "Fibromialgia" 1 => "Médicos de atención primaria" 2 => "Conocimientos" ] ] ] ] "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">Knowledge about fibromyalgia in general practitioners in the province of Chiclayo, Peru, 2016.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cross sectional descriptive study. Non-probability sampling, census type. In all, 145 physicians were evaluated through a questionnaire of 14 questions, validated by experts and a pilot. The analysis was performed using STATA v. 13.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Accuracy in questions involving diagnosis was 41.1% and in questions about treatment: 65%; 75.1% ‘had seen patients with fibromyalgia’ previously. The average on locating pain points was 2.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.8. Only 2.8% identified 11 or more painful points; 54.5% answered that ‘the diagnosis is clinical and exams are for the differential diagnosis’; 46.1% in Ministerio de Salud (MINSA) and 28.3% in Seguro Social de Salud (EsSalud) answered the item about diagnostic criteria (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.021); 65.7% said that psychotherapy, pregabalin and aerobic exercise were the most effective therapeutic triad, with no differences between MINSA and EsSalud: 61.5% vs 68.6% (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.23); 59.3% responded that drugs that had proved to be useful were: pregabalin, duloxetine and amitriptyline; 66.2% responded that the most effective physical therapy is aerobic exercise.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Knowledge of the diagnosis and treatment of fibromyalgia by general doctors in Chiclayo is poor. There are some differences in knowledge depending on the age and type of institution to which each belongs.</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">Describir los conocimientos en fibromialgia de los médicos de atención primaria de la provincia de Chiclayo durante el 2016.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo transversal, con un muestreo no probabilístico, tipo censal. Se evaluaron 145 médicos mediante un cuestionario de 14 preguntas, validado por expertos y con una prueba piloto. El análisis univariado y bivariado se realizó con STATA v. 13.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El acierto en las preguntas de diagnóstico fue del 41,1% y en las de tratamiento, del 65%. El 75,1% «habían visto pacientes con fibromialgia», previamente. La media de puntos dolorosos acertados fue de 2,2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2,8. Solo el 2,8% identificaron de 11 a más puntos dolorosos; el 54,5% respondieron que «el diagnóstico es clínico y los exámenes son para el diagnóstico diferencial». El 46,1% de los médicos del Ministerio de Salud del Perú (MINSA) y el 28,3% de los del Seguro Social de Salud (EsSalud) respondieron correctamente el ítem de criterios diagnósticos (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,021). El 65,7% respondieron que la psicoterapia, la pregabalina y el ejercicio aeróbico eran la tríada terapéutica más eficaz, sin diferencias entre MINSA y EsSalud, con un 61,5 y 68,6%, respectivamente (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,23). El 59,3% respondieron que los fármacos con utilidad demostrada son: pregabalina, duloxetina y amitriptilina. El 66,2% respondieron que la terapia física más eficaz es el ejercicio aeróbico.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El conocimiento en diagnóstico y tratamiento de la fibromialgia en médicos generales de Chiclayo es deficiente. Existen algunas diferencias en el conocimiento según la edad y el tipo de institución a la que pertenecen.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales 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: Acuña Ortiz FE, Capitán de la Cruz VA, León Jiménez FE. Conocimientos de fibromialgia en médicos de atención primaria de la provincia de Chiclayo-Perú, 2016. Reumatol Clin. 2017;13:326–330.</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">EsSalud, Social Health Insurance system; I, category indicating the level of complexity of the center; MINSA, Ministry of Health.</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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristic \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">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">% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleBold">Age</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic"><35 years</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.8 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">>35 years</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleBold">Sex</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Male</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.2 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Female</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleBold">Health institution</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">MINSA</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.7 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">EsSalud</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleBold">Level of complexity</span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">MINSA</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>I-3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.9 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>I-2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.8 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>I-4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.4 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>I-1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">EsSalud</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>I-3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.1 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>I-1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1572933.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Sociodemographic Characteristics of the Physicians Participating in the Questionnaire.</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">ACR, American College of Rheumatology.</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 " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Aspect evaluated by the questions</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Correct response</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">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">% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Diagnosis</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Age and characteristic age group \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64.1 \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"><span class="elsevierStyleHsp" style=""></span>The diagnosis is clinical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.5 \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"><span class="elsevierStyleHsp" style=""></span>Mental health comorbidities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.0 \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"><span class="elsevierStyleHsp" style=""></span>Diseases with similar symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.1 \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"><span class="elsevierStyleHsp" style=""></span>Associated comorbidities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.8 \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"><span class="elsevierStyleHsp" style=""></span>1990 ACR diagnostic criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37.9 \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"><span class="elsevierStyleHsp" style=""></span>Sleep problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.7 \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"><span class="elsevierStyleHsp" style=""></span>Location of tender points \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Treatment</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ideal multidisciplinary team \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">101 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.7 \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"><span class="elsevierStyleHsp" style=""></span>Most effective physical therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.2 \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"><span class="elsevierStyleHsp" style=""></span>Therapeutic alternatives \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64.8 \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"><span class="elsevierStyleHsp" style=""></span>Drugs with demonstrated utility \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1572932.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Overall Distribution of Correct Responses in the Questionnaire.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tratamiento sintomático y del dolor en fibromialgia mediante abordaje multidisciplinar desde Atención Primaria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. González" 1 => "M. del Teso" 2 => "C. Waliño" 3 => "J. Criado" 4 => "J. Sánchez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.reuma.2014.03.005" "Revista" => array:6 [ "tituloSerie" => "Reumatol Clin" "fecha" => "2015" "volumen" => "11" "paginaInicial" => "22" "paginaFinal" => "26" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24837647" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0110" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Worldwide epidemiology of fibromyalgia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L.P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 13 | 23 |
| 2024 October | 49 | 24 | 73 |
| 2024 September | 44 | 14 | 58 |
| 2024 August | 60 | 34 | 94 |
| 2024 July | 39 | 24 | 63 |
| 2024 June | 38 | 39 | 77 |
| 2024 May | 38 | 24 | 62 |
| 2024 April | 48 | 35 | 83 |
| 2024 March | 39 | 28 | 67 |
| 2024 February | 39 | 35 | 74 |
| 2024 January | 26 | 14 | 40 |
| 2023 December | 19 | 10 | 29 |
| 2023 November | 47 | 39 | 86 |
| 2023 October | 59 | 26 | 85 |
| 2023 September | 68 | 39 | 107 |
| 2023 August | 25 | 11 | 36 |
| 2023 July | 29 | 31 | 60 |
| 2023 June | 36 | 18 | 54 |
| 2023 May | 49 | 24 | 73 |
| 2023 April | 36 | 20 | 56 |
| 2023 March | 80 | 32 | 112 |
| 2023 February | 51 | 30 | 81 |
| 2023 January | 43 | 15 | 58 |
| 2022 December | 97 | 29 | 126 |
| 2022 November | 51 | 29 | 80 |
| 2022 October | 76 | 37 | 113 |
| 2022 September | 54 | 41 | 95 |
| 2022 August | 58 | 40 | 98 |
| 2022 July | 43 | 47 | 90 |
| 2022 June | 44 | 36 | 80 |
| 2022 May | 40 | 39 | 79 |
| 2022 April | 48 | 65 | 113 |
| 2022 March | 36 | 47 | 83 |
| 2022 February | 55 | 38 | 93 |
| 2022 January | 43 | 51 | 94 |
| 2021 December | 30 | 41 | 71 |
| 2021 November | 49 | 44 | 93 |
| 2021 October | 51 | 52 | 103 |
| 2021 September | 51 | 51 | 102 |
| 2021 August | 33 | 42 | 75 |
| 2021 July | 47 | 27 | 74 |
| 2021 June | 45 | 33 | 78 |
| 2021 May | 46 | 49 | 95 |
| 2021 April | 144 | 105 | 249 |
| 2021 March | 71 | 31 | 102 |
| 2021 February | 59 | 25 | 84 |
| 2021 January | 41 | 22 | 63 |
| 2020 December | 58 | 21 | 79 |
| 2020 November | 44 | 25 | 69 |
| 2020 October | 31 | 17 | 48 |
| 2020 September | 81 | 28 | 109 |
| 2020 August | 83 | 29 | 112 |
| 2020 July | 53 | 14 | 67 |
| 2020 June | 44 | 16 | 60 |
| 2020 May | 41 | 24 | 65 |
| 2020 April | 50 | 19 | 69 |
| 2020 March | 17 | 9 | 26 |
| 2020 February | 1 | 0 | 1 |
| 2018 July | 1 | 0 | 1 |
| 2018 May | 8 | 0 | 8 |
| 2018 April | 3 | 1 | 4 |
| 2018 March | 34 | 3 | 37 |
| 2018 February | 46 | 13 | 59 |
| 2018 January | 58 | 24 | 82 |
| 2017 December | 60 | 33 | 93 |
| 2017 November | 58 | 38 | 96 |
| 2017 October | 24 | 30 | 54 |
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