Brief report
Evolution over thirty years of the profile of inpatients with reactive arthritis in a tertiary rheumatology unit
Evolución durante 30 años del perfil de pacientes hospitalizados con artritis reactiva en una unidad de reumatología de tercer nivel
Anne Brinster, Xavier Guillot, Clément Prati, Daniel Wendling
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Service de Rhumatologie, CHRU de Besançon and Université de Franche-Comté, Besançon, France
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The classical clinical presentation is an acute oligo arthritis, mainly located at the lower limbs, with possibility of axial (sacro iliac and spine) involvement and enthesitis, as well as extra articular features (ophthalmologic or dermatologic symptoms). ReA is considered part of spondyloarthritis spectrum, sharing with this entity common clinical and imaging features, as well as frequent association with HLA-B27 haplotype.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,4</span></a> Outcome is variable, with possibility of resolution after several months, or relapses or chronic evolution, leading sometimes, after years, to ankylosing spondylitis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The aim of this study was to analyze, over 30 years, in new cases of ReA the clinical, biological and imaging characteristics, as well as management modalities, comparing two periods.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Patients and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">This is a descriptive, monocentric retrospective study of patients hospitalized in the Rheumatology department of the Centre Hospitalier Régional et Universitaire in Besançon, France, between January 1st 1984 and april 2014 with ReA as principal diagnosis, according to ICD codes M02 and M03. The charts were reviewed by experienced rheumatologists (AB, CP, DW) and patients were included if they fulfilled international classification criteria.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> The following data were recorded: demographic characteristics, HLA-B27 status, initial infection (location and bacteriological species) and its diagnosis method, as well as the potential antimicrobial treatment. Clinical features of ReA were noted: delay between infection and rheumatologic symptoms onset, general symptoms (fever), tender and swollen joint counts, presence of enthesitis or dactylitis, axial symptoms, and extra articular symptoms (conjunctivitis, uveitis, balanitis). The rheumatic treatments and their introduction delay were collected, as well as the outcome. For this purpose, we studied and compared charts of patients with ReA over two periods, from January 1984 to December 1993, and from January 2004 to December 2013.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Results were expressed as numbers for the microbiological findings, and means or percentage for clinic-biological data. <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span> test were used for comparisons of percentages, with Yates and Fisher corrections if needed, and Mann–Whitney if t test were not applicable. Significance threshold was <span class="elsevierStyleItalic">p</span> less than 0.05.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">One hundred and twenty charts were analyzed, and 62 were finally included, the causes of exclusion were wrong diagnosis and absence of classification criteria fulfilment. They were 52 men (83.9%) and 10 women (16.1%) with a mean age of 34 years (12–69). Six patients (10%) had a familial history of inflammatory rheumatic disease, four of them had a familial background of spondyloarthritis. At admission, 20% of the patients were febrile, and 82% had elevated biologic markers of inflammation (mean CRP 94<span class="elsevierStyleHsp" style=""></span>mg/l, leukocytes (WBC) 10.2<span class="elsevierStyleHsp" style=""></span>G/l). A complete urethro-oculo-synovial syndrome was noted in 19.4%. The mean number of painful joints was 3, and of swollen joints 2.1; two patients had no synovitis, but in one case we noticed axial symptoms with buttock pain and a dactylitis. The most frequently involved joints were the knee, then ankle, wrist and tarsal joints; dactylitis was present in 19.4% of the cases. Inflammatory back pain was mentioned in 22.3% of the cases, and enthesopathy in 24.2%, mainly talalgia. Among extra rheumatic involvement, conjunctivitis was the most frequent (27.4%); three cases of palmar and/or plantar pustulosis and three cases of balanitis were observed. HLA-B27 typing was positive in 36 out of 56 assessments (64.3%).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Urethritis was described in 43.6% and dysenteric syndrome in 21% of the cases. Eight cases exhibited no infectious symptoms, and in 7 of them, evidence of an infection was brought by systematic research. Rheumatologic symptoms appeared with a mean of 14.7 days after the supposed infection. Evidence of infection was found in 63.3%, with serological proof in 37%, PCR on urethral sampling in 14% and vaginal in 2%, blood and stool cultures in 2% of the 62 cases each. <span class="elsevierStyleItalic">Chlamydiae trachomatis</span> was the most frequent infectious agent (37% of the cases with evidence of infection), found in 83.3% by serology, 11% by PCR (uretral or vaginal), and 5.6% by both methods; in three cases it was associated with another infection (<span class="elsevierStyleItalic">streptococcus</span>, <span class="elsevierStyleItalic">Yersinia</span>, <span class="elsevierStyleItalic">gonococcus</span>). The following most frequent species were <span class="elsevierStyleItalic">Ureaplasma urealyticum</span> and <span class="elsevierStyleItalic">Neisseriae gonorrhoeae</span> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In 35 cases, an antibiotic treatment for the inaugural infection was mentioned.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Non steroidal anti inflammatory drugs (NSAIDs) were used in 91.8% of cases. The absence of use was due to contra indications or intolerance. Disease modifying anti rheumatic drugs (DMARDs) were introduced in 51.8% of patients with a median delay of 60 days from the first rheumatic symptoms, with salazosulfapyridin as the first choice. Use of TNF blockers was recorded in 15 patients (24.2%), mean age 35 years, with a median delay of 116 days.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The outcome was variable, and longstanding follow-up was available in 42 patients: with a mean follow-up duration of 34 months, 52% are in remission, under or without treatment, 44% developed spondyloarthritis, and 4% psoriatic arthritis,.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The comparison of the two cohorts did not reveal any significant change in the frequency of ReA in hospitalized patients or in the profile of these patients (<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>) (age, sex, type of infection, rheumatologic presentation or outcome). In the most recent period, the use of Azithromycin for treatment of Chlamydia, and of anti TNF agents were more frequent.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Reactive arthritis may have two backgrounds: epidemic, with classical description during world war 1st,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> and sporadic. It corresponds to arthritis related to a preceding infection outside the joint, mainly in the gut<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> or the genito urinary tract, with some classical species,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> and other less frequent (e.g. <span class="elsevierStyleItalic">Clostridium</span><a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> or <span class="elsevierStyleItalic">N. gonorrhoea</span>).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> The estimated annual incidence varies among studies and countries between 0.6 and 30/1,000,000 (4). Due to improvement in collective hygienic conditions, one may expect a reduction in incidence of ReA in developed countries. It has been recently shown a decline in ReA diagnoses despite an increase in chlamydia diagnoses over the 1992–2012 period in Sidney, Australia.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> Our results do not share this conclusion, in fact, the incidence of new cases of ReA in our department seems similar between the two periods of analysis (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), <span class="elsevierStyleItalic">Chlamydia</span> being the most frequent incriminated (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0055" class="elsevierStylePara elsevierViewall">The microbiological profile of potential triggers is tributary of the detection method. Direct evidence of infection is difficult to obtain, since the micro organism is no more present at the site of infection when arthritis occurs,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> and indirect assessments, mainly serologic tests, have limitations.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> The profile of microbiological species is not different between the recent period and 30 years ago in our series, with a similar proportion of bacteriological evidence missing despite use of new techniques in the recent period (e.g. polymerase chain reaction).</p><p id="par0060" class="elsevierStylePara elsevierViewall">The clinical presentation of rheumatologic features and extra articular manifestations did not differ significantly between the two periods.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Some changes were obvious in the therapeutic management. The type of antibiotics used for the treatment of the initial infection changed over the years, due to availability of new treatments, whereas, efficacy of antibiotics upon rheumatologic symptoms is still not demonstrated.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> The use of conventional synthetic DMARDs is similar over the two periods, but the use of anti TNF agents appear in the recent period; efficacy and safety of TNF blockers were observed in case reports<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> and observational series<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> in the recent years.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The outcome is more difficult to analyze, since one third of the patients were lost of follow-up after six months in the whole population. For patients with follow-up, half of them was considered in remission, with or without treatment, and the remaining developed chronic spondyloarthritis, illustrating the several phenotypes of the disease.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> Again, no significant changes were obvious in outcome between the two periods of observation. A recent paper analyzed the outcome of 21 cases of epidemic outbreak of ReA after waterbone gastro enteritis<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a>: after one year, one third of the patients demonstrated a chronic evolution, defined as a duration of arthritis over 6 months.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Our study has some limitations. The retrospective analysis, and some missing data, particularly in follow up, dim the conclusions. The absence of universal classification criteria, associated with the difficulty of diagnosis in cases without the evidence of infection represent another limitation. Referral biases arise for this kind of study, and the analysis performed only on inpatients in one department of the hospital. Due to the acute presentation, patients were referred via the general practitioner or the emergency room, without major change over the two periods (data not shown). Nevertheless, the large period of monocentric observation and the number of patients provide some interest for this analysis.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Our study confirms that ReA is still present in a tertiary rheumatology unit in a developed country, without major changes over 30 years in clinical presentation and microbiologic context. ReA keeps a potential evolution towards chronicity that justifies an early rheumatologic management and follow-up with tailored treatment.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Protection of human and animal subjects</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Confidentiality of data</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest concerning this manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres976250" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:1 [ "identificador" => "abst0005" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec945924" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres976251" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:1 [ "identificador" => "abst0025" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec945923" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Patients and methods" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Results" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-03-26" "fechaAceptado" => "2016-08-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec945924" "palabras" => array:5 [ 0 => "Reactive arthritis" 1 => "Spondyloarthritis" 2 => "Epidemiology" 3 => "Treatment" 4 => "Outcome" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec945923" "palabras" => array:5 [ 0 => "Artritis reactiva" 1 => "Espondiloartritis" 2 => "Epidemiología" 3 => "Tratamiento" 4 => "Resultado" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Reactive arthritis (ReA) is sterile arthritis occurring after extra articular bacterial infection. The aim of this study was to analyze, over 30 years, clinical, biological and imaging characteristics as well as therapeutic management of new cases of ReA, comparing two periods.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">retrospective monocentric study, data of all the patients followed in our unit between January 1st 1984 and April 2014 with the diagnosis or ReA were analyzed (clinical and biological features, management and outcome), and compared between two periods: from January 1984 to December 1993, and from January 2004 to December 2013.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sixty two patients fulfilling international diagnosis criteria were analyzed. There was no significant difference between the two periods in number of new cases, clinical presentation, biological data or outcome. Changes in therapeutic management were obvious with occurrence of anti TNF in the recent period.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reactive arthritis is still a current rheumatologic problem in a developed country, with a need of early and tailored rheumatologic management.</p></span>" "secciones" => array:4 [ 0 => array:1 [ "identificador" => "abst0005" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 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"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las artritis reactivas (ARe) son artritis estériles que se manifiestan después de una infección bacteriana extraarticular. El objetivo de este estudio es analizar, durante 30 años, las características clínicas, biológicas e imagenológicas, así como la gestión del tratamiento de la ARe, mediante la comparación de 2 periodos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo monocéntrico. Se analizaron los datos de todos los pacientes diagnosticados con ARe en nuestra unidad entre el 1 de enero de 1984 y abril de 2014 (rasgos clínicos y biológicos, gestión y resultados) y se compararon con 2 periodos: de enero de 1984 a diciembre de 1993, y de enero de 2004 a diciembre de 2013.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se analizaron los datos de 62 pacientes que cumplieron los criterios de diagnóstico internacionales. No existió una diferencia significativa entre los 2 periodos en la cantidad de casos, presentación clínica, datos biológicos o resultados. Los cambios de la gestión del tratamiento fueron evidentes, con la aparición de anti-TNF en el periodo reciente.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La artritis reactiva continúa siendo un problema reumatológico actual en los países desarrollados, con una necesidad de tratamiento reumatológico temprano y personalizado.</p></span>" "secciones" => array:4 [ 0 => array:1 [ "identificador" => "abst0025" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">PCR: polymerase chain reaction.</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">Infectious agent \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">Number of patients positive \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">Serology \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">PCR \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">Culture \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 " align="left" valign="top"><span class="elsevierStyleItalic">Chlamydia trachomatis</span> \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="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Ureaplasma urealyticum</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">N. gonorrhoea</span> \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="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Chlamydia</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">+</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Yersina</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Chlamydia</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">+</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Strepto B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Chlamydia</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">+</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">N. gonorrhoea</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Salmonella</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Neisseria meningitidis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Anguillulosis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Yersina</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">S. Aureus</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">+</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Strepto B</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Not found \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1653380.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of infectious agents.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">(ns<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>non significant) TJC: tender joint count; SJC: swollen joint count, DMARDs: disease modifying anti rheumatic drugs.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1984–1993 \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">2004–2013 \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"><span class="elsevierStyleItalic">p</span> \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 " align="left" valign="top">Number of patients included \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Number of patients hospitalized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7438 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 823 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Men \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Median age at diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">HLA B27+ (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Delay between infection/articular symptoms (days) median<br>mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.5<br>14.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9<br>14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patients with fever (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Leucocytes (giga/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">CRP (mean) (mg/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">87.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Evidence of infectious agent (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Antibiotic treatment (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Treatement by azithromycin (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.006 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">TJC/SJC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.8/1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.2/2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " 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">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Enthésitis (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Extra articular features (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Axial symptoms (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">DMARDs use (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Median delay of DMARD introduction (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">210 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Biologic agents use (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Remission at last follow-up (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1653379.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">“Global” comparison of the 2 cohorts.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "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">Infectious agent (%) \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">1984–1993 (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>15) \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">2004–2013 (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>31) \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"><span class="elsevierStyleItalic">p</span> \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 " align="left" valign="top"><span class="elsevierStyleItalic">Chlamydia</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">N. gonorrhoea</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Mycoplasma</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Ureaplasma</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Salmonella</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \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="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Anguillulosis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \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="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Yersinia</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Not found \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1653378.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Distribution of infective agents found in cases of reactive arthritis between the two periods.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "HL-A antigen 27 and reactive arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "K. Aho" 1 => "P. Ahvonen" 2 => "A. Lassus" 3 => "K. Sievers" 4 => "A. Tilikainen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Lancet" "fecha" => "1973" "volumen" => "2" "paginaInicial" => "157" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12849237" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0085" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Third International Workshop on Reactive Arthritis. 23–26 September 1995, Berlin, Germany. Report and abstracts" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G. Kingsley" 1 => "J. Sieper" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Rheum Dis" "fecha" => "1996" "volumen" => "55" "paginaInicial" => "564" "paginaFinal" => "584" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8815821" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0090" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reactive arthritis: clinical aspects and medical management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.D. Carter" 1 => "A.P. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 6 | 6 | 12 |
| 2024 Octubre | 50 | 26 | 76 |
| 2024 Septiembre | 55 | 20 | 75 |
| 2024 Agosto | 65 | 32 | 97 |
| 2024 Julio | 60 | 24 | 84 |
| 2024 Junio | 74 | 29 | 103 |
| 2024 Mayo | 84 | 33 | 117 |
| 2024 Abril | 72 | 29 | 101 |
| 2024 Marzo | 81 | 31 | 112 |
| 2024 Febrero | 60 | 30 | 90 |
| 2024 Enero | 49 | 25 | 74 |
| 2023 Diciembre | 39 | 26 | 65 |
| 2023 Noviembre | 49 | 21 | 70 |
| 2023 Octubre | 65 | 37 | 102 |
| 2023 Septiembre | 112 | 37 | 149 |
| 2023 Agosto | 57 | 16 | 73 |
| 2023 Julio | 56 | 21 | 77 |
| 2023 Junio | 54 | 18 | 72 |
| 2023 Mayo | 57 | 20 | 77 |
| 2023 Abril | 46 | 8 | 54 |
| 2023 Marzo | 87 | 32 | 119 |
| 2023 Febrero | 83 | 32 | 115 |
| 2023 Enero | 50 | 24 | 74 |
| 2022 Diciembre | 81 | 47 | 128 |
| 2022 Noviembre | 63 | 40 | 103 |
| 2022 Octubre | 90 | 43 | 133 |
| 2022 Septiembre | 58 | 53 | 111 |
| 2022 Agosto | 55 | 48 | 103 |
| 2022 Julio | 53 | 61 | 114 |
| 2022 Junio | 48 | 38 | 86 |
| 2022 Mayo | 52 | 42 | 94 |
| 2022 Abril | 70 | 50 | 120 |
| 2022 Marzo | 69 | 55 | 124 |
| 2022 Febrero | 48 | 32 | 80 |
| 2022 Enero | 50 | 57 | 107 |
| 2021 Diciembre | 56 | 47 | 103 |
| 2021 Noviembre | 51 | 66 | 117 |
| 2021 Octubre | 74 | 64 | 138 |
| 2021 Septiembre | 52 | 44 | 96 |
| 2021 Agosto | 52 | 60 | 112 |
| 2021 Julio | 38 | 36 | 74 |
| 2021 Junio | 44 | 42 | 86 |
| 2021 Mayo | 60 | 50 | 110 |
| 2021 Abril | 126 | 119 | 245 |
| 2021 Marzo | 67 | 55 | 122 |
| 2021 Febrero | 50 | 32 | 82 |
| 2021 Enero | 67 | 28 | 95 |
| 2020 Diciembre | 60 | 33 | 93 |
| 2020 Noviembre | 74 | 38 | 112 |
| 2020 Octubre | 53 | 33 | 86 |
| 2020 Septiembre | 58 | 40 | 98 |
| 2020 Agosto | 45 | 32 | 77 |
| 2020 Julio | 42 | 29 | 71 |
| 2020 Junio | 52 | 28 | 80 |
| 2020 Mayo | 61 | 27 | 88 |
| 2020 Abril | 38 | 23 | 61 |
| 2020 Marzo | 79 | 32 | 111 |
| 2020 Febrero | 64 | 32 | 96 |
| 2020 Enero | 75 | 33 | 108 |
| 2019 Diciembre | 58 | 35 | 93 |
| 2019 Noviembre | 46 | 8 | 54 |
| 2019 Octubre | 51 | 10 | 61 |
| 2019 Septiembre | 81 | 28 | 109 |
| 2019 Agosto | 80 | 28 | 108 |
| 2019 Julio | 61 | 32 | 93 |
| 2019 Junio | 34 | 34 | 68 |
| 2019 Mayo | 55 | 48 | 103 |
| 2019 Abril | 35 | 32 | 67 |
| 2019 Marzo | 45 | 45 | 90 |
| 2019 Febrero | 27 | 17 | 44 |
| 2019 Enero | 43 | 27 | 70 |
| 2018 Diciembre | 96 | 64 | 160 |
| 2018 Noviembre | 173 | 27 | 200 |
| 2018 Octubre | 117 | 22 | 139 |
| 2018 Septiembre | 29 | 14 | 43 |
| 2018 Agosto | 24 | 12 | 36 |
| 2018 Julio | 26 | 17 | 43 |
| 2018 Junio | 0 | 1 | 1 |
| 2018 Marzo | 67 | 33 | 100 |
| 2018 Febrero | 170 | 121 | 291 |
| 2018 Enero | 71 | 32 | 103 |
| 2017 Diciembre | 0 | 10 | 10 |
| 2017 Noviembre | 0 | 11 | 11 |
| 2017 Octubre | 0 | 6 | 6 |
| 2017 Septiembre | 0 | 8 | 8 |
| 2017 Agosto | 0 | 11 | 11 |
| 2017 Julio | 0 | 12 | 12 |
| 2017 Junio | 0 | 20 | 20 |
| 2017 Mayo | 0 | 16 | 16 |
| 2017 Abril | 0 | 13 | 13 |
| 2017 Marzo | 0 | 12 | 12 |
| 2017 Febrero | 0 | 17 | 17 |
| 2017 Enero | 0 | 14 | 14 |
| 2016 Diciembre | 0 | 29 | 29 |
| 2016 Noviembre | 0 | 25 | 25 |
| 2016 Octubre | 0 | 56 | 56 |
| 2016 Septiembre | 14 | 37 | 51 |
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