Special Article
Fibromyalgia’s main features, widespread pain, and insomnia in the paintings of Remedios Varo
Las manifestaciones primordiales de la fibromialgia, dolor generalizado e insomnio, en la pintura de Remedios Varo
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Gouache/cartulina, 1947. Reproducido con autorización de la Visual Entidad de Gestión de Artistas Plásticos de España y de la Sociedad Mexicana de Autores de las Artes Plásticas. D.R. © Remedios Varo/VEGAP/SOMAAP/México/2023.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Brenda J. Caro-Cocotle, Lucía Peñalosa, María-Fernanda Mejía-Ávila, Angélica Vargas-Guerrero, Manuel Martínez-Lavín" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Brenda J." 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Caro-Cocotle, Lucía Peñalosa, María-Fernanda Mejía-Ávila, Angélica Vargas-Guerrero, Manuel Martínez-Lavín" "autores" => array:5 [ 0 => array:3 [ "nombre" => "Brenda J." "apellidos" => "Caro-Cocotle" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Lucía" "apellidos" => "Peñalosa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "María-Fernanda" "apellidos" => "Mejía-Ávila" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Angélica" "apellidos" => "Vargas-Guerrero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:4 [ "nombre" => "Manuel" "apellidos" => "Martínez-Lavín" "email" => array:1 [ 0 => "drmartinezlavin@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Museo de Arte Moderno de la Ciudad de México, INBAL/Secretaría de Cultura, Mexico City, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Reumatología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Las manifestaciones primordiales de la fibromialgia, dolor generalizado e insomnio, en la pintura de Remedios Varo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1349 "Ancho" => 1005 "Tamanyo" => 208652 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Insomnia I. Gouache/paperboard, 1947. Reproduced with permission of the Visual Entidad de Gestión de Artistas Plásticos de España and the Sociedad Mexicana de Autores de las Artes Plásticas. D.R. © Remedios Varo/VEGAP/SOMAAP/México/2023.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fibromyalgia is a highly common disease which most affects women and is characterised by widespread chronic pain and other discomforting symptoms such as insomnia, fatigue and cognitive alterations. It is now known that fibromyalgia pain is neuropathic in origin, which is why it is accompanied by externalised “paraesthesias” such as prickling, tingling and/or cramps.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The sensitivity of women artists to pain has been expressed in many different ways. An iconic case is Frida Kahlo, who transferred her own illness to canvas. When talking about her suffering, Frida said “pain is not part of life, it can become life itself”. A meticulous study of Frida's biography and medical history indicates that fibromyalgia was the cause of her chronic pain.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> From an entirely different perspective and setting, another painter contemporary to Frida, the artist Remedios Varo, used part of her commercial and advertising creative work to illustrate the primary symptoms of fibromyalgia: widespread pain and insomnia.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this article is to review the circumstances which led Remedios Varo to interpret the principal symptoms of fibromyalgia into a top-quality creative work of art with communicative sensitivity. With the appropriate licences, this article reproduces two works by Remedios Varo appropriate entitled “<span class="elsevierStyleItalic">Dolor reumático II</span>” <span class="elsevierStyleItalic">(Rheumatic pain II) and “Insomnio I” (Insomnia 1)</span> in which the painter interprets the main discomforts of people suffering from fibromyalgia in an original and dramatic manner.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Biography</span><p id="par0020" class="elsevierStylePara elsevierViewall">María de los Remedios Alicia Rodriga Varo y Uranga was born on 16th December 1908 in Anglés, in the province of Gerona, España. From a very young age she travelled to several places in Spain and North Africa, accompanying her father who was a hydraulic engineer. These trips introduced her to different cultures, and her father also who introduced her to technical drawing and encouraged her in her interest in literature.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Remedios was one of the first women to enter the San Fernando Academy of Fine Arts in Madrid, obtaining a master's degree in drawing in 1930. Years later, in Barcelona, she joined the logico-phobic group that sought to unite surrealism with spiritualism. In 1937, as a result of the Spanish Civil War, she went into exile in Paris, where she joined a surrealist circle close to André Breton.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The Second World War drew this avant-garde artist onto the Mexican beaches along with a plethora of European freethinkers. Remedios arrived in Veracruz in 1941. To subsist in her new reality, she took on various commercial jobs, including decorating furniture and musical instruments and designing costumes for plays. From 1947 to 1949 she travelled to Venezuela as part of a French scientific expedition and also to be reunited with her family, then living in the country. There she worked as a draughtswoman for the Ministry of Health, devoting herself to scientific drawing, in particular the graphic recording of insect specimens as part of a social communication campaign against malaria. She also worked on various advertising commissions for the Mexican pharmaceutical company Bayer, including the two works that are the subject of this article.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In 1952, now back in Mexico, she began a relationship with the Austrian refugee Walter Gruen. The support of this music-loving businessman enabled Remedios to devote herself entirely to painting and to enter the most fruitful period of her artistic career. Remedios Varo died in Mexico City on 8 October 1963 of a heart attack.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Artistic interpretation of impalpable human suffering</span><p id="par0040" class="elsevierStylePara elsevierViewall">In the late 1940s, the pharmaceutical company Bayer de México, through Abastecedora de Impresos S.A., commissioned Remedios Varo to produce a series of paintings to illustrate various symptoms that were the therapeutic targets of the medicines produced by the laboratory. Documents held in the Remedios Varo Art Fund at the Museum of Modern Art in Mexico City show the themes suggested by the company (malaria, vitamins, pain, anaesthesia, rheumatism, women's internal hygiene, vaginal discharge, among others), together with a series of ideas and concepts to be developed for their representation. For example, for pain they proposed: “inquisition, tortures, middle ages”; for rheumatism: “sanctuary of Lourdes, representing crutches, objects of invalids, etc.”. Bayer, however, gave Remedios complete freedom to interpret various pathologies. These commissioned paintings were signed with the artist's maternal surname “Uranga”. These early works helped the young painter to find her own style<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and have ceased to be considered a minor work, not only because they mark a stage of transition from surrealist influence to an artistic language of her own, but also because of the depth with which she was able to express the subjective perception of pain and the exhausting experience of insomnia.</p><p id="par0045" class="elsevierStylePara elsevierViewall">It should be noted that the case of Remedios Varo is not exceptional in the Mexican artistic field. Other artists such as José Horna, also a Spanish exile and a close friend of the painter's, worked commercially as a means of subsistence or alternative employment. What is remarkable, however, is Varo’s ability to combine the need for information and effective communication in advertising with a refined formal display, compositional technique and artistic execution.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040"><span class="elsevierStyleItalic">Rheumatic pain II</span>. Gouache/paperboard, 1948</span><p id="par0050" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows a woman with a rictus of pain; her foreshortened body is arched by suffering and covered with bandages that both convey illness and reaffirm her anatomy at the same time. The twisted hands corroborate the suffering. The woman levitates on a thorny wasteland, enduring the pricks of multiple nails and also of the spikes that emerge from the earth. A stormy sky dramatises the scene. Rheumatic pain II communicates suffering, generalised pain and paraesthesia.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rheumatic pain II</span> advertised the drug Neo-melubrin (metamizole), which was used at the time to relieve various types of musculoskeletal pain. In the advertising leaflet given to doctors, the following text accompanied the image: “It’s as if sharp nails were sinking into the flesh, the joints, the bones, the nerves! Such are the sensations suffered by those who suffer from rheumatism, lumbago, sciatica!”<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045"><span class="elsevierStyleItalic">Insomnia I</span>. Gouache/paperboard, 1947</span><p id="par0060" class="elsevierStylePara elsevierViewall">In <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, from the distant darkness, a sequence of tired female gazes can be seen passing through several desolate rooms. They reflect, perhaps, the inability to fall asleep as the inhospitable night hours pass. An austere window allows a glimpse of the darkness of the night. In front, the light of a candlestick attracts insects with crystalline wings. Insomnia I advertised several barbiturate drugs, including Evipan (sodium hexobarbital) and Abasin (acecarbromal), which have been discontinued due to their various adverse effects.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In a pamphlet kept in the Remedios Varo art collection of the Museum of Modern Art in Mexico City, the following interpretation of Insomnio I reads: “They have the impression that someone is watching them and it is they who open their tired eyelids, scrutinising the nocturnal shadows! Indefinite anguish fills the solitude of these dark, dry rooms, devoid of warmth. The solemn silence sharpens the desire to hear, and from one's own entrails the noise of the beating of the cardiac cycle systoles and diastoles is born and grows bigger… Insomnia… Father of worries; forger of concerns…!!!!! Artist who paints in purple tones, dark circles of fatigue..”</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Commentary</span><p id="par0070" class="elsevierStylePara elsevierViewall">The inclusion of original, avant-garde works of art such as those produced by Remedios Varo in the advertising of medicines is unparalleled in pharmacological marketing. The leaflets distributed to doctors contained the visual representation of the symptom, together with the name of the pills recommended for its relief. The works produced for Bayer allowed Remedios to define a series of formal and compositional elements that were the basis of her later work, such as the anatomy of the figures, the spatiality, the settings, the iconographic and thematic repertoire.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These early works also show the artist's keenness to understand the environment of commercial advertising aimed at doctors. Varo was able to transcend the mere commercial purpose of the commission to create scenes of great empathy and narrative force.</p><p id="par0075" class="elsevierStylePara elsevierViewall">There is no reason to think that Remedios Varo had any notion of the concept of fibromyalgia, or fibrositis, as the disease was called at the time. Nor is there any evidence that she suffered from chronic pain, although in a letter to her friend Kati Horna she mentioned that she suffered from tiredness and “rheumatism”.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> At that time fibromyalgia as a clinical entity was virtually unknown to the medical community. People suffering from this syndrome were labelled with pejorative diagnoses such as hysteria, neurosis or hypochondria. The medical misogyny of that time, which still survives today, somehow blamed patients for their own suffering.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">What is certain is that these 2 works by Remedios Varo represent in a dramatic and original way the fundamental and most discomforting manifestations of fibromyalgia. Although the symptoms cannot be read as a reflection of the artist's personal condition, they do open a bridge where art can provide tools to translate, narrate or express physical and psychological states for which verbal expression is not enough.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interests</span><p id="par0085" class="elsevierStylePara elsevierViewall">All the authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres2003345" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1716476" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2003344" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1716477" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Biography" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Artistic interpretation of impalpable human suffering" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Rheumatic pain II. Gouache/paperboard, 1948" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Insomnia I. Gouache/paperboard, 1947" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Commentary" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-02-27" "fechaAceptado" => "2023-04-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1716476" "palabras" => array:5 [ 0 => "Fibromyalgia" 1 => "Insomnia" 2 => "Pain" 3 => "Paresthesias" 4 => "Remedios Varo" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1716477" "palabras" => array:5 [ 0 => "Fibromialgia" 1 => "Insomnio" 2 => "Dolor" 3 => "Parestesias" 4 => "Remedios Varo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The sensitivity of plastic artists to human suffering has been expressed in different ways. This article recounts the circumstances that led the Spanish-Mexican surrealist painter, Remedios Varo, to depict in an original way the two cardinal manifestations of fibromyalgia; widespread pain and insomnia.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La sensibilidad de las artistas plásticas ante el sufrimiento humano ha quedado plasmada de diversas maneras. Este artículo relata las circunstancias que llevaron a la pintora surrealista hispano-mexicana, Remedios Varo, a representar en forma original las dos manifestaciones cardinales de la fibromialgia; dolor generalizado e insomnio.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1342 "Ancho" => 1005 "Tamanyo" => 473024 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Rheumatic pain II. Gouache/paperboard, 1948. Reproduced with permission of the Visual Entidad de Gestión de Artistas Plásticos de España and the Sociedad Mexicana de Autores de las Artes Plásticas. D.R. © Remedios Varo/VEGAP/SOMAAP/Mexico/2023.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1349 "Ancho" => 1005 "Tamanyo" => 208652 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Insomnia I. Gouache/paperboard, 1947. Reproduced with permission of the Visual Entidad de Gestión de Artistas Plásticos de España and the Sociedad Mexicana de Autores de las Artes Plásticas. D.R. © Remedios Varo/VEGAP/SOMAAP/México/2023.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fibromyalgia in women: somatisation or stress-evoked, sex-dimorphic neuropathic pain?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. Martínez-Lavín" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.55563/clinexprheumatol/0c7d6v" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Rheumatol" "fecha" => "2021" "volumen" => "39" "paginaInicial" => "422" "paginaFinal" => "425" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32940205" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fibromyalgia in Frida Kahlo’s life and art" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Martínez-Lavín" 1 => "M.C. Amigo" 2 => "J. Coindreau" 3 => "J. Canoso" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/1529-0131(200003)43:3<708::AID-ANR30>3.0.CO;2-0" "Revista" => array:6 [ "tituloSerie" => "Arthritis Rheum" "fecha" => "2000" "volumen" => "43" "paginaInicial" => "708" "paginaFinal" => "709" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10728769" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Cinco Llaves del mundo secreto de Remedios Varo. México: Ed. Artes de México; 2008." ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Galindo CB. Viajes Inesperados. El Arte Y La Vida De Remedios Varo, De Janet A. Kaplan. Anales Del Instituto De Investigaciones Estéticas. 1990. <a target="_blank" href="https://doi.org/10.22201/iie.18703062e.1990.61.1563">https://doi.org/10.22201/iie.18703062e.1990.61.1563</a>." ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Carta de Remedios Varo a Kati Horna, 23 de mayo 1948 en Fuga epis-tolar desarrollado en el marco de la exhibición Constelaciones, deRemedios Varo (Malba, 2020) [Accessed 14 February 2022]. Available from: <a target="_blank" href="https://malba.s3.sa-east-1.amazonaws.com/wp-content/uploads/2020/05/Remedios-Varo-Fuga-Epistolar.pdf">https://malba.s3.sa-east-1.amazonaws.com/wp-content/uploads/2020/05/Remedios-Varo-Fuga-Epistolar.pdf</a>." ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001900000008/v3_202311021029/S2173574323001144/v3_202311021029/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/21735743/0000001900000008/v3_202311021029/S2173574323001144/v3_202311021029/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574323001144?idApp=UINPBA00004M" ]
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