Special Article
Screening of Inflammatory Bowel Disease and Spondyloarthritis for Referring Patients Between Rheumatology and Gastroenterology
Criterios de cribado de enfermedad inflamatoria intestinal y espondiloartritis para derivación de pacientes entre Reumatología y Gastroenterología
Jesús Sanz Sanza,
, Xavier Juanola Rourab, Daniel Seoane-Matoc, Miguel Montorod, Fernando Gomollóne, PIIASER Project Working Group ◊
Corresponding author
a Servicio de Reumatología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
b Servicio de Reumatología, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
c Unidad de Investigación, Sociedad Española de Reumatología, Madrid, Spain
d Unidad de Gastroenterología y Hepatología, Hospital General San Jorge, Huesca, Spain
e Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo. Hospital Clínico Universitario «Lozano Blesa», Zaragoza, Spain
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"aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Gastroenterología y Hepatología, Hospital General San Jorge, Huesca, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo. Hospital Clínico Universitario «Lozano Blesa», Zaragoza, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Criterios de cribado de enfermedad inflamatoria intestinal y espondiloartritis para derivación de pacientes entre Reumatología y Gastroenterología" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3013 "Ancho" => 1884 "Tamanyo" => 359634 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">IBD screening criteria for patients with SpA. Initial version.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Musculoskeletal symptoms are the extraintestinal manifestations most frequently associated with inflammatory bowel disease (IBD). Patients with IBD frequently develop spondyloarthritis (SpA). According to a meta-analysis published in 2016, the prevalence of peripheral arthritis is around 13%, sacroiliitis around 10% and ankylosing spondylitis 3%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In a cohort of 269 patients with IBD evaluated for joint pain, 50.5% were diagnosed with SpA; an average diagnostic delay of 5.2 years was observed.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In another study of 122 patients with IBD, the prevalence of SpA was 28.7%, of whom 45.7% were not previously diagnosed despite a history of inflammatory lower back pain and/or peripheral arthritis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">By comparison, according to the data of a meta-analysis published in 2015, the prevalence of IBD in ankylosing spondylitis is 6.8%.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The studies also revealed a link between psoriatic arthritis and the onset of IBD, although to a lesser degree.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">And although not as long as with SpA, there is also a diagnostic delay in the case of IBD. In a series of 1591 patients with IBD, in 25% of cases this delay exceeded two years for Crohn's disease (CD) and one year for ulcerative colitis (UC).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In another series of 1196 patients, the delay times were 18 months for CD and three months for UC.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">For both SpA and IBD it is very important to avoid diagnostic delay because it is associated with a worse clinical course and poorer response to treatment.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10–13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Currently, there are no tools aimed at providing an early diagnosis for SpA in patients with IBD, and vice versa, that are adapted to the Spanish healthcare system. The objective of this article is to define clinical screening criteria for SpA in patients with IBD and vice versa, which serve as a reference in patient referral between the Rheumatology and Digestive System departments for the early detection of these diseases.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">General Design</span><p id="par0040" class="elsevierStylePara elsevierViewall">Systematic review of the literature and consensus using the two-round Delphi method.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Selection of Scientific Committee and Panel Members</span><p id="par0045" class="elsevierStylePara elsevierViewall">To make this selection, the experience (both clinical and investigational) of the candidates with regard to the project subject matter and their research CVs (publications from the last five years and participation in research projects) were evaluated. In the case of the scientific committee members, their personal qualities and attitude towards working in a group were also evaluated. For the selection of panellists, the geographic representation of the Spanish territory and the type of hospital (level 1 or basic hospitals, level 2 or reference hospitals, and level 3 or high-tech hospitals) were also evaluated.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The scientific committee was made up of two rheumatologists and two gastroenterologists. The panel of experts included seven rheumatologists and seven gastroenterologists.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Literature Review</span><p id="par0055" class="elsevierStylePara elsevierViewall">Two systematic reviews of the literature were conducted, one of which focused on the screening tools or the suspected IBD gastroenterologist referral criteria, and the other focusing on screening tools or suspected SpA (not including psoriatic arthritis) rheumatologist referral criteria. Both were limited to a population under the age of 18. The searches (<a class="elsevierStyleCrossRef" href="#sec0105">Appendix B</a>) were performed using Pubmed, Embase and Cochrane Library, and include articles in Spanish and English published until January 2016.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Definition of the Screening Criteria</span><p id="par0060" class="elsevierStylePara elsevierViewall">Using the results obtained in the systematic review stage and considering their experience, the members of the scientific committee defined the potential components of the screening criteria. In this respect, the sensitivity, specificity, ease of use in normal clinical practice and standardisation (ensuring that variability in their application is as low as possible) criteria were considered.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The two-round Delphi method was then initiated. The selected panellists evaluated the proposed criteria electronically. The panellists were provided with systematic review reports from the literature in advance. The scores for each criterion were calculated according to the following scale: 1<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>absolute disagreement; 2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>moderate disagreement; 3<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>neither agree nor disagree; 4<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>moderate agreement, and 5<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>absolute agreement.</p><p id="par0070" class="elsevierStylePara elsevierViewall">For each of these criteria, the panellists could make comments about changes that may be considered necessary in the wording or reasons explaining their evaluation if deemed necessary, or provide additional evidence (not collected in the systematic review reports) that supported their scoring. The panellists could also propose additional criteria.</p><p id="par0075" class="elsevierStylePara elsevierViewall">After analysing the results of this first Delphi round, the scientific committee evaluated the criteria for which there was no consensus, as well as the suggestions for additional criteria. A second document was then prepared outlining the criteria for which there had been no consensus in the first round, together with the changes made by the scientific committee according to the comments and suggested criteria. The first round scores and comments from the panellists for the non-consensual criteria were also included, as well as the scientific committee's response to these comments.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In the second round, this document was sent to the panellists, who once again evaluated the criteria for which no consensus had been reached, aware of the result of the first round so that they could compare their initial score with that of the other panellists and the considerations of the scientific committee. The criteria were evaluated according to the same scale used in the first round.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The anonymity of the participants was maintained throughout the entire Delphi process.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Analysis of the Delphi Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">The level of consensus for each item was defined as the percentage of panellists who gave a score ≥4, and the level of disagreement as the percentage of scores ≤2.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The following thresholds were used to define consensus:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0100" class="elsevierStylePara elsevierViewall">Consensus: score ≥4 from at least 75% of the panellists.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">–</span><p id="par0105" class="elsevierStylePara elsevierViewall">Disagreement: score ≤2 from at least 75% of the panellists.</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">Those items for which there was consensus in the first or second Delphi round formed part of the final screening criteria.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0115" class="elsevierStylePara elsevierViewall">The initial screening criteria defined by the scientific committee are outlined in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results of the First Delphi Round</span><p id="par0120" class="elsevierStylePara elsevierViewall">The evaluations of 13 panellists were collected. <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> show the level of consensus reached for each item proposed by the scientific committee.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">For the IBD screening, four of the panellists suggested that calprotectin be included, one panellist considered it necessary to include the age at which the symptoms started, and another suggested that the presence of mucus in faeces be included as a minor criterion.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Regarding the SpA screening, the following suggestions for inclusion in the criteria were made (each of these suggested by one panellist): axial morning stiffness lasting more than one hour; morning stiffness lasting more than 30<span class="elsevierStyleHsp" style=""></span>min in the case of axial or peripheral articular symptoms; presence of previous or current uveitis; articular pain lasting at least three months and starting before the age of 45; and alternating buttock pain.</p><p id="par0135" class="elsevierStylePara elsevierViewall">After evaluating the criteria for which no consensus was reached (level of consensus below 75%) and the comments of the panellists, the scientific committee decided:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">–</span><p id="par0140" class="elsevierStylePara elsevierViewall">Not to make any changes to the criterion concerning vitamin B12 deficiency.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">–</span><p id="par0145" class="elsevierStylePara elsevierViewall">To amend the criterion on fever or febricula, with no apparent focality, to the following: fever or febricula, with no apparent focality, lasting more than one week.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">–</span><p id="par0150" class="elsevierStylePara elsevierViewall">For the rectal bleeding criterion, although the level of consensus was 100%, the following change was made based on the panellists’ comments: rectal bleeding, unless haemorrhoidal signs are evident and there are haemorrhoids on physical examination.</p></li></ul></p><p id="par0155" class="elsevierStylePara elsevierViewall">Regarding possible additional criteria, the scientific committee evaluated the suggestions received in the first round and it was decided that alternating buttock pain be included, combining it with the inflammatory lower back pain criterion so that the final wording of the criterion was as follows: inflammatory lower back pain (according to the Assessment of SpondyloArthritis international Society [ASAS] definition) or alternating buttock pain.</p><p id="par0160" class="elsevierStylePara elsevierViewall">The scientific committee decided not to include faecal calprotectin in the IBD screening for patients with SpA because they believe it is a tool that is still not accessible to a large proportion of Rheumatology departments. Furthermore, they believe that including this item could run the risk of over-indication in the request for this test. As a result, it was decided that the request for calprotectin should currently be limited to the gastroenterology setting. The panellists were informed of this decision at the beginning of the second Delphi round. One of the panellists commented, “the fact that faecal calprotectin is not available at this time does not mean that it won’t be widely available in the next few months or years. It is such a simple tool with so much negative predictive value that it is now suggested to be used as screening for organic gastrointestinal disorders in patients with chronic diarrhoea, and it has been recommended that it become available in the Primary Care setting”.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results of the Second Delphi Round</span><p id="par0165" class="elsevierStylePara elsevierViewall">In this Delphi round, the panellists once again evaluated the two non-consensual criteria from the first round, taking into account the change made by the scientific committee to the fever or febricula criterion. For this reason, the scores and comments of the other panellists were provided, as well as the scientific committee's response to these comments. They also evaluated whether to include alternating buttock pain in the inflammatory lower back pain criterion.</p><p id="par0170" class="elsevierStylePara elsevierViewall">A total of 13 panellists took part. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the level of consensus for each of the criteria.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">For vitamin B12 deficiency, one of the panellists, who scored this criterion with a two (moderate disagreement), supplied the systematic review by Battat et al. to justify his/her evaluation and to provide more information.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> This systematic review includes 42 studies that analyse serum cobalamin levels and the absorption test. According to the results of these studies, neither CD nor UC would predispose to a vitamin B12 deficiency. Considering this reference and the low specificity of this marker, the scientific committee believed it unnecessary to include the B12 deficiency in the IBD screening criteria for patients with SpA. The panellists were notified of this decision and none opposed it.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Final Version of the Screening Criteria</span><p id="par0180" class="elsevierStylePara elsevierViewall">The screening criteria defined according to the process described above are outlined in <a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0185" class="elsevierStylePara elsevierViewall">In studies conducted in various countries (we have not been able to find published data relating to Spain), it was observed that a significant percentage of patients with IBD and musculoskeletal manifestations who were referred to the Gastroenterology department were not evaluated by the Rheumatology department.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,15</span></a> Furthermore, in accordance with the data from the Swiss IBD cohort, the presence of extraintestinal manifestations (including peripheral arthritis and ankylosing spondylitis) could be associated with a diagnostic delay in CD.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">This article proposes some IBD screening criteria for patients with SpA and SpA screening criteria for patients with IBD, with the aim of facilitating early diagnosis. These criteria are based on the systematic review of the literature and the experiences of the scientific committee members and the panel of experts. For their definition, we sought an ease of use in consultation and that variability among physicians in their application be as low as possible.</p><p id="par0195" class="elsevierStylePara elsevierViewall">We were only able to find one study on tools for the early detection of SpA in patients with IBD.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> That study describes the development and analysis of the reliability of a questionnaire aimed at detecting cases of axial SpA. As in this article, the majority of the information collected relates to characteristics typical of axial inflammatory pain and the existence of peripheral arthritis, enthesitis or dactylitis. The differences include a longer self-administered questionnaire, since it contains some aspects not included in the screening criteria, specifically, family history of ankylosing spondylitis, morning back stiffness, response of pain to anti-inflammatory drugs and personal history of uveitis or psoriasis.</p><p id="par0200" class="elsevierStylePara elsevierViewall">Regarding these differences, in patients from the ESPeranza cohort (multicentre state-run programme for the early diagnosis and treatment of SpA, in which patients with suspected SpA were referred from Primary Care to 25 SpA units over a three-year period), among the various characteristics of SpA, family history and response to nonsteroidal anti-inflammatory drugs (NSAIDs) had the lowest diagnostic value in patients with axial SpA during the initial stages (symptoms lasting 3–24 months).<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Moreover, uveitis was not included in the screening criteria because it is an extraintestinal manifestation of IBD itself. The starting point for the definition of these criteria was the ASAS recommendations for the referral of patients with suspected axial SpA.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">In the systematic literature review, we did not find any clinical tools for the early detection of IBD in patients with SpA. In the Netherlands, the Dudley Inflammatory Bowel Symptom Questionnaire (DISQ; a self-administered questionnaire developed and validated to evaluate intestinal symptoms in IBD) was validated in order to evaluate the presence and severity of intestinal symptoms in patients with axial SpA.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Significant differences were found in the average score between healthy controls and patients with SpA, and between those with SpA and those with CD. Furthermore, the DISQ score was correlated with SpA activity. 31% of the patients with SpA obtained a score ≥11, which would reflect intestinal symptoms that are sufficiently severe to affect quality of life, and approximately 7.8% presented with symptoms compatible with active IBD (DISQ score ≥19). This questionnaire is not adapted to the Spanish population and we have not been able to find validation studies in other populations.</p><p id="par0210" class="elsevierStylePara elsevierViewall">Calprotectin is a protein produced by monocytes, macrophages and neutrophils, which is released by these cells at the site of inflammation. Despite the contrasted usefulness of faecal calprotectin in the detection of IBD in patients with gastrointestinal symptoms,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> its validity as an IBD screening method in patients with SpA is not currently well defined. Its values are positively correlated with the SpA activity parameters and are higher in patients with no gastrointestinal symptoms; this elevation could be a risk marker for developing IBD.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a> Taking into account the risk of over-indication and the lack of access for a large proportion of the Rheumatology departments, it was decided that the request for this test should currently be limited to the gastroenterology setting. Depending on its availability, practicability and suitability for use in Rheumatology consultations, its inclusion may be evaluated in the future.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Regarding the strengths of the study, it should be noted that the level of consensus was very high (over 90%) for all the criteria included. Some authors have suggested a threshold of 80% in order to validate the content when there are fewer than ten experts taking part in the consensus process.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,24</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">The Spanish Society of Rheumatology (<span class="elsevierStyleItalic">Sociedad Española de Reumatología</span>, SER) has sponsored this project, in collaboration with the Spanish Association of Gastroenterology (<span class="elsevierStyleItalic">Asociación Española de Gastroenterología</span>, AEG) and the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (<span class="elsevierStyleItalic">Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa</span>, GETECCU). Gastroenterologists and rheumatologists who work in various autonomous communities took part, ensuring a sufficiently wide geographic representation for the scientific committee and panel of experts.</p><p id="par0225" class="elsevierStylePara elsevierViewall">One limitation that must be mentioned is that there were no level-1 hospital specialists on the scientific committee or the panel. However, since these are criteria based fundamentally on clinical practice, their applicability does not depend on the technical complexity of the hospital.</p><p id="par0230" class="elsevierStylePara elsevierViewall">New studies are required to complete the validation of the criteria defined (a study of their proper application by the specialists involved, as well as their sensitivity and specificity).</p><p id="par0235" class="elsevierStylePara elsevierViewall">In conclusion, IBD screening criteria have been identified for patients with SpA and vice versa. These have to be of use in the early detection of these disorders in order to ensure that the patients can benefit from a comprehensive treatment of the disease in its initial stages. Their fundamentally clinical nature will enable their use by specialists at the different hospital levels.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Ethical Disclosures</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Protection of human and animal subjects</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that no experiments on humans or animals have been conducted in this research.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Confidentiality of data</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors declare that no patient data are contained in this article.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Right to privacy and informed consent</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors declare that no patient data are contained in this article.</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding</span><p id="par0255" class="elsevierStylePara elsevierViewall">This project was funded by MSD, which did not take part in the design, collection and analysis of data, or the drafting of this article.</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Authorship</span><p id="par0260" class="elsevierStylePara elsevierViewall">J. Sanz Sanz and X. Juanola Roura are the main authors.</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicts of Interest</span><p id="par0265" class="elsevierStylePara elsevierViewall">JSS declares that he has no conflict of interest with regard to the article. XJR received funding from MSD for a teaching collaboration and attendance at a conference. MM has taught three courses funded by MSD. FG received funding from MSD to participate in conferences and for research. DSM declares that he has no conflicts of interest with regard to the article. None of the members of the PIIASER Project Working Group have received payment for participating in the study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1006173" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec965926" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1006174" "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" => "xpalclavsec965927" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and Methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "General Design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Selection of Scientific Committee and Panel Members" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Literature Review" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Definition of the Screening Criteria" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Analysis of the Delphi Results" ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Results of the First Delphi Round" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Results of the Second Delphi Round" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Final Version of the Screening Criteria" ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0065" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0070" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0075" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0080" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0085" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0090" "titulo" => "Authorship" ] 11 => array:2 [ "identificador" => "sec0095" "titulo" => "Conflicts of Interest" ] 12 => array:2 [ "identificador" => "xack339328" "titulo" => "Acknowledgements" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-03-05" "fechaAceptado" => "2017-07-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec965926" "palabras" => array:4 [ 0 => "Spondyloarthropathies" 1 => "Inflammatory bowel diseases" 2 => "Screening" 3 => "Early diagnosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec965927" "palabras" => array:4 [ 0 => "Espondiloartropatías" 1 => "Enfermedades inflamatorias del intestino" 2 => "Cribado" 3 => "Diagnóstico precoz" ] ] ] ] "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">To define clinical screening criteria for spondyloarthritis (SpA) in patients with inflammatory bowel disease (IBD) and vice versa, which can be used as a reference for referring them to the rheumatology or gastroenterology service.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Systematic literature review and a two-round Delphi method. The scientific committee and the expert panel were comprised of 2 rheumatologists and 2 gastroenterologists, and 7 rheumatologists and 7 gastroenterologists, respectively. The scientific committee defined the initial version of the criteria, taking into account sensitivity, specificity, standardisation and ease of application. Afterwards, members of the expert panel assessed each item in a two-round Delphi survey. Items that met agreement in the first or second round were included in the final version of the criteria.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Positive screening for SpA if at least one of the following is present: onset of chronic low back pain before 45 years of age; inflammatory low back pain or alternating buttock pain; HLA-B27 positivity; sacroiliitis on imaging; arthritis; heel enthesitis; dactylitis. Positive screening for IBD in the presence of one of the major criteria or at least two minor criteria. Major: rectal bleeding; chronic diarrhoea with organic characteristics; perianal disease. Minor: chronic abdominal pain; iron deficiency anaemia or iron deficiency; extraintestinal manifestations; fever or low grade fever, of unknown origin and duration >1week; unexplained weight loss; family history of IBD.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Screening criteria for IBD in patients with SpA, and vice versa, have been developed. These criteria will be useful for early detection of both diseases.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "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">Definir criterios clínicos de cribado de espondiloartritis (SpA) en pacientes con enfermedad inflamatoria intestinal (EII) y vice versa, que sirvan de referencia en la derivación entre Reumatología y Aparato Digestivo.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisión sistemática de la literatura y Delphi a dos rondas. Formaron parte del comité científico 2 reumatólogos y 2 digestólogos; del panel de expertos, 7 reumatólogos y 7 digestólogos. El comité científico definió los componentes potenciales de los criterios, teniendo en cuenta aspectos de sensibilidad, especificidad, facilidad de uso y estandarización. A continuación, se realizó el Delphi. Aquellos ítems para los que hubo acuerdo en primera o segunda ronda formaron parte de la versión final de los criterios.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Cribado positivo de SpA si se cumple al menos uno de los siguientes: dolor lumbar crónico con inicio antes de los 45 años; dolor lumbar inflamatorio o dolor alternante en nalgas; HLA-B27 positivo; sacroilitis en pruebas de imagen; artritis; entesitis del talón; dactilitis. Cribado positivo de EII si uno de los criterios mayores o al menos dos de los menores. Mayores: rectorragia; diarrea crónica de características orgánicas; enfermedad perianal. Menores: dolor abdominal crónico; anemia ferropénica o ferropenia; manifestaciones extraintestinales; fiebre o febrícula, sin focalidad aparente y de más de una semana de duración; pérdida de peso no explicable; antecedentes familiares de EII.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se han definido criterios de cribado de EII en pacientes con SpA y viceversa. Estos han de ser de utilidad en la detección precoz de dichas patologías.</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:3 [ 0 => array:3 [ "etiqueta" => "◊" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">The members of the PIIASER Project Working Group are listed in <a class="elsevierStyleCrossRef" href="#sec0100">Appendix A</a>.</p>" "identificador" => "fn1" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sanz Sanz J, Juanola Roura X, Seoane-Mato D, Montoro M, Gomollón F, Grupo de Trabajo del proyecto PIIASER. Criterios de cribado de enfermedad inflamatoria intestinal y espondiloartritis para derivación de pacientes entre Reumatología y Gastroenterología. Reumatol Clin. 2018;14:68–74.</p>" ] 2 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This article is published simultaneously in Gastroenterología y Hepatología: <a class="elsevierStyleInterRef" target="_blank" id="intr0010" href="https://doi.org/10.1016/j.gastre.2017.07.013">10.1016/j.gastre.2017.07.013</a>, with the consent of the authors and editors.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:2 [ 0 => array:4 [ "apendice" => "<p id="par0275" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Scientific committee:</span> Jesús Sanz Sanz, Xavier Juanola Roura, Miguel Montoro, Fernando Gomollón.</p> <p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Panel of experts:</span> Carlos Montilla Morales (Hospital Clínico Universitario de Salamanca).</p> <p id="par0285" class="elsevierStylePara elsevierViewall">Raquel Almodóvar González (Hospital Universitario Fundación Alcorcón).</p> <p id="par0290" class="elsevierStylePara elsevierViewall">Juan Cañete Crespillo (Hospital Clínic de Barcelona).</p> <p id="par0295" class="elsevierStylePara elsevierViewall">Rubén Queiro Silva (Hospital Universitario Central de Asturias).</p> <p id="par0300" class="elsevierStylePara elsevierViewall">María del Carmen Castro Villegas (Hospital Universitario Reina Sofía).</p> <p id="par0305" class="elsevierStylePara elsevierViewall">Enrique Ornilla Laraudogoitia (Clínica Universidad de Navarra).</p> <p id="par0310" class="elsevierStylePara elsevierViewall">Miguel Mínguez (Hospital Clínico Universitario de Valencia).</p> <p id="par0315" class="elsevierStylePara elsevierViewall">Montserrat Aceituno (Hospital Universitario Mútua de Terrasa).</p> <p id="par0320" class="elsevierStylePara elsevierViewall">Marta Carrillo (Hospital Universitario de Canarias).</p> <p id="par0325" class="elsevierStylePara elsevierViewall">Yolanda Arguedas (Hospital General San Jorge de Huesca).</p> <p id="par0330" class="elsevierStylePara elsevierViewall">Manuel Barreiro (Complejo Hospitalario Universitario de Santiago).</p> <p id="par0335" class="elsevierStylePara elsevierViewall">Belén Beltrán (Hospital Universitario y Politécnico La Fe de Valencia).</p> <p id="par0340" class="elsevierStylePara elsevierViewall">Ignacio Marín (Hospital General Universitario Gregorio Marañón de Madrid).</p>" "etiqueta" => "Appendix A" "titulo" => "PIIASER Project Working Group" "identificador" => "sec0100" ] 1 => array:4 [ "apendice" => "<p id="par0350" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix B" "titulo" => "Supplementary Data" "identificador" => "sec0110" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1558 "Ancho" => 1620 "Tamanyo" => 229826 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">SpA screening criteria for patients with IBD. Initial version.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3013 "Ancho" => 1884 "Tamanyo" => 359634 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">IBD screening criteria for patients with SpA. Initial version.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2153 "Ancho" => 2112 "Tamanyo" => 300012 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">SpA screening criteria for patients with IBD.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2763 "Ancho" => 1875 "Tamanyo" => 363988 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">IBD screening criteria for patients with SpA.</p>" ] ] 4 => 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="spar0070" class="elsevierStyleSimplePara elsevierViewall">IBD: inflammatory bowel disease; SpA: spondyloarthritis.</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">Criterion \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">Level of consensus \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">Chronic lower back pain starting before the age of 45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92% (12 of the 13 panellists) \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">Inflammatory lower back pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92% (12 of the 13 panellists) \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">HLA-B27 positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92% (12 of the 13 panellists) \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">Sacroiliitis in imaging tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92% (12 of the 13 panellists) \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">Arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \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 enthesitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \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">Dactylitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1703953.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">SpA Screening Criteria for Patients With IBD. Level of Consensus.</p>" ] ] 5 => 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="spar0080" class="elsevierStyleSimplePara elsevierViewall">IBD: inflammatory bowel disease; SpA: spondyloarthritis.</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">Criterion \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">Level of consensus \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="2" align="left" valign="top"><span class="elsevierStyleItalic">Major criteria</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>Rectal bleeding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \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>Organic chronic diarrhoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \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>Perianal disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" 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="2" align="left" valign="top"><span class="elsevierStyleItalic">Minor criteria</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>Chronic abdominal pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \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>Iron-deficiency anaemia or iron deficiency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92% (12 of the 13 panellists) \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>Vitamin B12 deficiency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69% (9 of the 13 panellists) \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>Extraintestinal manifestations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92% (12 of the 13 panellists) \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>Fever or febricula, with no focality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62% (8 of the 13 panellists) \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>Unexplained weight loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92% (12 of the 13 panellists) \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>Family history of IBD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1703955.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">IBD Screening Criteria for Patients With SpA. Level of Consensus.</p>" ] ] 6 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><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">Criterion \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">Level of consensus \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">Vitamin B12 deficiency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77% (10 of the 13 panellists) \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">Fever or febricula, with no apparent focality, lasting more than one week \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \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">Inflammatory lower back pain (according to the ASAS definition) or alternating buttock pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1703954.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Level of Consensus With the Criteria. Second Delphi Round.</p>" ] ] 7 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 86465 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The prevalence and incidence of axial and peripheral spondyloarthritis in inflammatory bowel disease: a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.C. Karreman" 1 => "J.J. Luime" 2 => "J.M. Hazes" 3 => "A.E. 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Mercedes Guerra Rodríguez for conducting the bibliographic searches in the systematic literature review.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001400000002/v1_201803210429/S217357431830025X/v1_201803210429/en/main.assets" "Apartado" => array:4 [ "identificador" => "5793" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Special article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001400000002/v1_201803210429/S217357431830025X/v1_201803210429/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357431830025X?idApp=UINPBA00004M" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 11 | 19 |
| 2024 October | 64 | 30 | 94 |
| 2024 September | 85 | 15 | 100 |
| 2024 August | 89 | 44 | 133 |
| 2024 July | 61 | 37 | 98 |
| 2024 June | 86 | 69 | 155 |
| 2024 May | 78 | 33 | 111 |
| 2024 April | 71 | 25 | 96 |
| 2024 March | 82 | 32 | 114 |
| 2024 February | 75 | 30 | 105 |
| 2024 January | 58 | 27 | 85 |
| 2023 December | 47 | 31 | 78 |
| 2023 November | 80 | 40 | 120 |
| 2023 October | 67 | 36 | 103 |
| 2023 September | 99 | 35 | 134 |
| 2023 August | 52 | 18 | 70 |
| 2023 July | 60 | 29 | 89 |
| 2023 June | 56 | 31 | 87 |
| 2023 May | 53 | 25 | 78 |
| 2023 April | 46 | 15 | 61 |
| 2023 March | 121 | 34 | 155 |
| 2023 February | 99 | 43 | 142 |
| 2023 January | 63 | 18 | 81 |
| 2022 December | 81 | 37 | 118 |
| 2022 November | 94 | 45 | 139 |
| 2022 October | 84 | 51 | 135 |
| 2022 September | 55 | 39 | 94 |
| 2022 August | 65 | 47 | 112 |
| 2022 July | 43 | 42 | 85 |
| 2022 June | 41 | 48 | 89 |
| 2022 May | 52 | 41 | 93 |
| 2022 April | 99 | 86 | 185 |
| 2022 March | 77 | 68 | 145 |
| 2022 February | 71 | 35 | 106 |
| 2022 January | 73 | 52 | 125 |
| 2021 December | 69 | 42 | 111 |
| 2021 November | 70 | 51 | 121 |
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| 2021 August | 34 | 45 | 79 |
| 2021 July | 38 | 34 | 72 |
| 2021 June | 44 | 32 | 76 |
| 2021 May | 62 | 62 | 124 |
| 2021 April | 139 | 156 | 295 |
| 2021 March | 78 | 23 | 101 |
| 2021 February | 48 | 27 | 75 |
| 2021 January | 54 | 23 | 77 |
| 2020 December | 57 | 29 | 86 |
| 2020 November | 61 | 27 | 88 |
| 2020 October | 29 | 21 | 50 |
| 2020 September | 37 | 24 | 61 |
| 2020 August | 32 | 20 | 52 |
| 2020 July | 36 | 20 | 56 |
| 2020 June | 48 | 22 | 70 |
| 2020 May | 35 | 23 | 58 |
| 2020 April | 32 | 17 | 49 |
| 2020 March | 35 | 15 | 50 |
| 2020 February | 1 | 0 | 1 |
| 2019 December | 33 | 2 | 35 |
| 2018 October | 0 | 1 | 1 |
| 2018 May | 1 | 0 | 1 |
| 2018 March | 1 | 2 | 3 |
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