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MACE&#41;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; Sin embargo&#44; la aparici&#243;n de MACE no se debe exclusivamente a factores de riesgo habituales&#44; como la hipertensi&#243;n arterial&#44; la dislipidemia&#44; la diabetes mellitus o la obesidad&#46; La naturaleza inflamatoria de la enfermedad tambi&#233;n desempe&#241;a un papel importante<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a>&#46; Los reactantes de fase aguda&#44; como la prote&#237;na C reactiva &#40;PCR&#41; o la velocidad de sedimentaci&#243;n globular &#40;VSG&#41;&#44; que se utilizan en el seguimiento de la artritis cr&#243;nica&#44; se han asociado con la rigidez de la pared arterial<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> y el aumento del riesgo cardiovascular<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La obesidad tiene una alta prevalencia en sujetos tanto con psoriasis como con APs&#44; en comparaci&#243;n con individuos sanos<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a>&#46; El sobrepeso causa una inflamaci&#243;n sist&#233;mica de bajo grado y se asocia con niveles m&#225;s altos de PCR y VSG<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a>&#44; lo que puede conducir a errores al evaluar a los pacientes obesos&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Al considerar la interacci&#243;n entre obesidad y enfermedad existe evidencia que indica que la obesidad es un predictor negativo tanto de la efectividad como de la persistencia de una respuesta adecuada al tratamiento biol&#243;gico y no biol&#243;gico en pacientes con APs<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a>&#46; Sin embargo&#44; esa interacci&#243;n es bidireccional&#58; las citocinas proinflamatorias que participan en la aparici&#243;n y el mantenimiento de enfermedades inmunomediadas tambi&#233;n promueven el s&#237;ndrome metab&#243;lico<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a>&#46; Por tanto&#44; existen trabajos que indican que el tratamiento de las artropat&#237;as inflamatorias podr&#237;a mejorar el perfil metab&#243;lico y el riesgo cardiovascular de este tipo de pacientes<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a>&#44; aunque la evidencia al respecto no es muy clara&#44; al menos en la APs<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El objetivo de nuestro trabajo es dual&#46; Por un lado&#44; queremos comprobar si existen interacciones entre el estado metab&#243;lico del paciente&#44; los par&#225;metros inflamatorios y la enfermedad evaluada por diferentes herramientas &#40;&#237;ndice Disease Activity in Psoriatic Arthritis &#91;DAPSA&#93;&#44; Minimal Disease Activity &#91;MDA&#93; y HAQ&#41;&#46; Por otro lado&#44; queremos evaluar si las enfermedades metab&#243;licas o cardiovasculares tienen alguna asociaci&#243;n con la reducci&#243;n de la carga inflamatoria por el tratamiento de la APs&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todo</span><p id="par0030" class="elsevierStylePara elsevierViewall">Hemos realizado un estudio descriptivo transversal de 160 pacientes con APs de un servicio de Reumatolog&#237;a de un hospital terciario del noreste de Espa&#241;a durante un per&#237;odo comprendido desde junio de 2018 a marzo de 2019&#46; Se incluy&#243; a pacientes ambulatorios de ambos sexos mayores de 18 a&#241;os&#44; diagnosticados de APs seg&#250;n la Criterios de ClASificaci&#243;n para la artritis psori&#225;sica &#40;CASPAR&#41;&#46; Se incluyeron pacientes con y sin tratamientos modificadores de la enfermedad&#46; No excluimos a ning&#250;n paciente&#46; Se realiz&#243; una consulta adicional a todos los pacientes para la recopilaci&#243;n de datos&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Los procedimientos del estudio incluyeron la recolecci&#243;n de variables sociodemogr&#225;ficas&#44; cl&#237;nicas&#44; anal&#237;ticas y radiogr&#225;ficas&#46; Para la prescripci&#243;n de medicamentos sist&#233;micos&#44; as&#237; como para la evaluaci&#243;n de los objetivos terap&#233;uticos&#44; se siguieron las recomendaciones actualizadas de manejo de la APs dadas por la Sociedad Espa&#241;ola de Reumatolog&#237;a&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Seg&#250;n el patr&#243;n articular dominante en los &#250;ltimos 5 a&#241;os de seguimiento&#44; los pacientes fueron diagnosticados de formas oligoarticulares de APs si ten&#237;an un m&#225;ximo de 4 articulaciones inflamadas&#59; poliartritis si ten&#237;an 5 o m&#225;s articulaciones inflamadas&#44; y se siguieron los criterios ASAS para espondiloartritis axial para la definici&#243;n de formas axiales&#46; Tambi&#233;n se recogi&#243; la presencia de dactilitis o entesitis&#44; tanto si estaba presente en el momento de la recogida de datos como si estaba registrada en la historia cl&#237;nica previa&#46; La afectaci&#243;n de las articulaciones interfal&#225;ngicas distales se registr&#243; como otra caracter&#237;stica de la APs&#44; pero no como un patr&#243;n articular espec&#237;fico&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Tanto el &#237;ndice DAPSA&#44; que se centra en la afectaci&#243;n articular&#44; como el MDA&#44; una medida binaria del estado de la enfermedad que cubre dominios importantes de la APs &#40;incluidas las articulaciones&#44; la piel y las entesis&#41;&#44; han demostrado tener validez de constructo y son f&#225;ciles de realizar en la pr&#225;ctica cl&#237;nica&#46; Los utilizamos tanto para evaluar la actividad de la enfermedad &#40;DAPSA&#41; como los objetivos de tratamiento &#40;MDA y remisi&#243;n de DAPSA&#41; en el presente trabajo&#46; Los pacientes se consideraron en MDA cuando cumpl&#237;an al menos 5 de los siguientes criterios&#58; recuento de articulaciones dolorosas<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>1&#59; recuento de articulaciones inflamadas<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>1&#59; Psoriasis Area and Severity Index<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>1 o &#225;rea de superficie corporal<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>3&#37;&#59; puntuaci&#243;n de la escala visual anal&#243;gica del dolor del paciente<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>15&#59; puntuaci&#243;n global de la escala visual anal&#243;gica de la actividad de la enfermedad del paciente<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>20&#59; puntuaci&#243;n HAQ<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;5&#59; y n&#250;mero de entesis dolorosas<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>1&#46; La puntuaci&#243;n DAPSA se calcul&#243; sumando el n&#250;mero de articulaciones sensibles e hinchadas&#44; dolor en la escala visual anal&#243;gica&#44; evaluaci&#243;n global del paciente y PCR&#46; La DAPSA cl&#237;nica se calcul&#243; sin la contribuci&#243;n de la PCR&#46; Las puntuaciones de DAPSA y DAPSA cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>4 identificaron un estado de remisi&#243;n&#46; Hemos utilizado la versi&#243;n espa&#241;ola del cuestionario de discapacidad HAQ para evaluar la calidad de vida de los pacientes</p><p id="par0050" class="elsevierStylePara elsevierViewall">Se registraron los factores de riesgo cardiometab&#243;lico &#40;obesidad&#44; diabetes&#44; hipertensi&#243;n arterial&#44; dislipidemia y tabaquismo&#41; y los eventos adversos cardiovasculares &#40;angina&#44; infarto de miocardio&#44; ictus e isquemia arterial perif&#233;rica&#41; de todos los pacientes&#46; En el caso de los factores de riesgo cardiometab&#243;licos&#44; solo se registraron si estaban presentes en el momento de la visita&#46; Los valores normales de PCR y VSG se establecen en 0&#44;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y 20<span class="elsevierStyleHsp" style=""></span>mm&#47;h respectivamente&#44; de acuerdo con los puntos de corte de nuestro laboratorio&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Los estad&#237;sticos descriptivos se expresan en porcentajes&#44; medias o medianas&#44; y se indica el rango intercuart&#237;lico &#40;RIC&#41; si procede&#46; Para realizar comparaciones entre variables cualitativas se utiliz&#243; la prueba de chi-cuadrado&#44; y para variables cuantitativas&#44; la t de Student&#44; la U de Mann-Whitney y la H de kruskall Wallis&#44; dependiendo de la normalidad o no de la distribuci&#243;n de las variables&#44; considerando p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 como estad&#237;sticamente significativo&#46; Tambi&#233;n hemos utilizado la odds ratio &#40;OR&#41; para medir la asociaci&#243;n entre el tratamiento y diferentes resultados o eventos&#44; como MACE&#44; DAPSA&#44; MDA&#44; PCR y VSG&#46; Para establecer correlaciones entre IMC&#44; circunferencia de cintura&#44; PCR&#44; ESR&#44; DAPSA&#44; HAQ y MDA&#59; se ha utilizado el coeficiente de correlaci&#243;n de Pearson&#46; Cumplir con los criterios de MDA es un valor cualitativo&#44; por lo que se registr&#243; como un valor binario&#58; 0<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>no cumple con los criterios&#59; 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>cumple con los criterios&#44; por lo que una relaci&#243;n negativa con esta variable indica una asociaci&#243;n con el cumplimiento de los criterios MDA&#46; Se utiliz&#243; el software IBM SPSS Statistics 19&#46;0 para el an&#225;lisis de datos&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Nuestra serie incluy&#243; 77 mujeres y 83 hombres&#46; La edad media es 54 a&#241;os &#40;RIC&#58; 44&#44;25-64&#44;75&#41; y la duraci&#243;n media de la enfermedad es 10&#44;6 a&#241;os &#40;RIC&#58; 4-15&#41;&#46; En cuanto a los datos antropom&#233;tricos&#44; el IMC medio de nuestros pacientes es de 28&#44;3 &#40;RIC&#58; 24&#44;53-30&#44;88&#41; y la media de per&#237;metro abdominal es de 101&#44;1<span class="elsevierStyleHsp" style=""></span>cm &#40;RIC&#58; 92&#44;25-108&#44;75&#41; en nuestra serie&#44; aunque no hemos diferenciado entre hombres y mujeres&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Aproximadamente un tercio de nuestra serie padece alg&#250;n factor de riesgo cardiovascular&#44; siendo los m&#225;s frecuentes la hipertensi&#243;n arterial &#40;28&#37;&#41;&#44; la dislipidemia &#40;25&#37;&#41; y la obesidad &#40;33&#37;&#41;&#44; seguidos del tabaquismo &#40;24&#37;&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">El patr&#243;n oligoarticular fue el m&#225;s frecuente en nuestra serie &#40;44&#37;&#41;&#44; seguido del patr&#243;n poliarticular &#40;26&#37;&#41; y de las formas mixta &#40;23&#37;&#41;&#44; siendo la forma exclusivamente axial la menos frecuente &#40;7&#37;&#41;&#46; El 25&#37; de nuestra serie ten&#237;a entesitis y afectaci&#243;n de las articulaciones interfal&#225;ngicas distales&#46; Por otro lado&#44; el 41&#37; de los individuos ten&#237;a dactilitis&#46; Las erosiones est&#225;n presentes en el 12&#37; de la poblaci&#243;n incluida&#46; Un 3&#37; han presentado uve&#237;tis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">La mediana de DAPSA es 6 &#40;RIC&#58; 2-12&#41;&#44; mientras que los reactantes de fase aguda son negativos en la mayor&#237;a de nuestra serie&#58; mediana de PCR&#58; 0&#44;2 &#40;RIC&#58; 0&#44;1-0&#44;6&#41;&#59; media de VSG&#58; 6&#44;5 &#40;RIC&#58; 3-15&#41;&#46; La mediana de HAQ es 0&#44;25 &#40;RIC&#58; 0-0&#44;6&#41;&#46; El 66&#37; de nuestra muestra cumple con los criterios de la MDA&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">En nuestra serie hay 50 pacientes en tratamiento con f&#225;rmacos modificadores de la enfermedad sint&#233;ticos &#40;FAME-S&#41;&#58; 43 pacientes con metotrexato&#44; 6 pacientes con leflunomida y uno paciente con sulfasalazina&#46; Hay 89 individuos que reciben tratamiento con terapias biol&#243;gicas &#40;FAME-B&#41;&#58; 67 pacientes con anti-TNF&#945; &#40;iTNF&#41;&#44; 18 pacientes con ustekinumab y 4 pacientes con secukinumab&#46; Los 21 pacientes restantes no reciben ning&#250;n tratamiento espec&#237;fico debido al buen control de la enfermedad&#46; Todos estos datos se recogen en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">El IMC y el per&#237;metro abdominal se correlacionan positivamente con la PCR y la VSG &#40;significaci&#243;n bilateral<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; aunque el grado de correlaci&#243;n es bajo &#40;Pearson<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;4&#41;&#46; No encontramos relaci&#243;n entre el IMC o la circunferencia de la cintura y DAPSA o cumplir con los criterios de MDA&#46; Tambi&#233;n existe una correlaci&#243;n entre la PCR y la VSG con DAPSA y el cumplimiento de los criterios de la MDA &#40;significaci&#243;n bilateral&#58;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Estos datos se recopilan en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Al evaluar la relaci&#243;n entre enfermedades metab&#243;licas&#44; reactantes de fase aguda&#44; DAPSA y HAQ&#59; encontramos que la hipertensi&#243;n arterial se asocia con valores m&#225;s altos de VSG &#40;U de Mann-Whitney&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;019&#41; y HAQ &#40;U de Mann-Whitney&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;049&#41;&#44; mientras que la hiperuricemia se asocia con niveles m&#225;s altos de PCR &#40;U de Mann-Whitney&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;026&#41;&#46; No encontramos asociaci&#243;n con el resto de enfermedades metab&#243;licas&#46; Estos datos se recopilan en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Si comprobamos las asociaciones entre el tratamiento y las diferentes enfermedades que integran el s&#237;ndrome metab&#243;lico&#44; nos encontramos con que el tratamiento de la APs no modifica ninguna de ellas&#46; No obstante&#44; estas enfermedades han sido registradas de manera cualitativa &#40;s&#237; est&#225; presente o no est&#225; presente&#41;&#46; No se han recogido los valores de presi&#243;n arterial&#44; glucemia&#44; colesterol&#44; triglic&#233;ridos y &#225;cido &#250;rico&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">El uso de FAME-B se asocia con una menor prevalencia de MACE en comparaci&#243;n con FAME-S &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;047&#59; OR&#58; 0&#44;12&#59; IC 95&#37;&#58; 0&#44;01-0&#44;9&#41;&#46; Tambi&#233;n encontramos una menor prevalencia de entesitis &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#59; OR&#58; 0&#44;3&#59; IC 95&#37;&#58; 0&#44;16-0&#44;56&#41;&#44; as&#237; como una mayor probabilidad de tener menor DAPSA &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#59; OR&#58; 0&#44;28&#59; IC 95&#37;&#58; 0&#44;11-0&#44;72&#41; o cumplir con los criterios de la MDA &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; OR&#58; 3&#44;65&#59; IC 95&#37;&#58; 1&#44;63-8&#44;13&#41;&#44; y mayor probabilidad de tener niveles normales de PCR &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;029&#59; OR&#58; 0&#44;25&#59; IC 95&#37;&#58; 0&#44;07-0&#44;87&#41; y VSG &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;024&#59; OR&#58; 0&#44;36&#59; IC 95&#37;&#58; 0&#44;16-0&#44;82&#41; en el grupo que recibe tratamiento con FAME-B en comparaci&#243;n con el grupo que recibe FAME-S&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><p id="par0105" class="elsevierStylePara elsevierViewall">Tanto las enfermedades metab&#243;licas como el riesgo cardiovascular son 2 aspectos que muchas veces se pasan por alto en el manejo rutinario de los pacientes con APs&#44; a pesar de que est&#225; bien documentado que estos pacientes suelen tener un perfil desfavorable en ambos &#225;mbitos&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Nuestros resultados indican que existe una correlaci&#243;n positiva entre las medidas antropom&#233;tricas &#40;IMC y per&#237;metro abdominal&#41; y los reactantes de fase aguda &#40;PCR y VSG&#41;&#44; pero cuando se compara con DAPSA o con los criterios MDA&#44; no existe tal relaci&#243;n&#46; Esto indica que en pacientes obesos podemos encontrar reactantes de fase aguda elevados sin que esto necesariamente se asocie con una mayor actividad de la enfermedad&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Si evaluamos la asociaci&#243;n entre el tratamiento y las diferentes enfermedades metab&#243;licas de nuestros pacientes&#44; comprobamos que el tratamiento de la enfermedad no se asocia con una menor prevalencia de hipertensi&#243;n&#44; dislipidemia&#44; diabetes o hiperuricemia&#46; Tampoco existen diferencias en la prevalencia de estas enfermedades metab&#243;licas entre los diferentes grupos de tratamiento &#40;FAME-S frente a FAME-B&#41;&#46; Por otro lado&#44; encontramos una menor prevalencia de entesitis y eventos cardiovasculares en el grupo FAME-B en comparaci&#243;n con el grupo FAME-S&#46; Estos resultados concuerdan con otros estudios en los que la entesitis se asoci&#243; con un aumento del riesgo cardiovascular en pacientes con APs<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a>&#46; Tambi&#233;n existen diferencias en los niveles de PCR y VSG&#44; donde encontramos que el tratamiento con FAME-B se asocia con mayor frecuencia a niveles normales de ambos reactantes de fase aguda en comparaci&#243;n con los que reciben tratamiento con FAME-S&#44; lo que tambi&#233;n podr&#237;a explicar la diferencia en la prevalencia de eventos cardiovasculares entre esos grupos<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">De todas las enfermedades metab&#243;licas incluidas en nuestro estudio&#44; solo la hipertensi&#243;n arterial y la hiperuricemia se asocian a valores m&#225;s altos de PCR&#44; VSG o HAQ&#44; pero no la diabetes o la dislipidemia&#44; probablemente debido al protocolo de recogida de datos&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">La obesidad implica un exceso de tejido adiposo&#44; el cual cl&#225;sicamente se ha considerado como un tejido de reserva de energ&#237;a&#46; Sin embargo&#44; esto es una percepci&#243;n err&#243;nea&#46; El tejido adiposo act&#250;a como un &#243;rgano endocrino&#44; en tanto que produce citocinas antiinflamatorias y proinflamatorias&#44; llamadas adipocinas<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a>&#46; En situaciones de aporte cal&#243;rico superior a las necesidades corporales&#44; el adipocito inicialmente se hipertrofia para mantener la funci&#243;n normal del tejido adiposo y permite la formaci&#243;n de nuevos adipocitos &#40;hiperplasia&#41;&#46; Este fen&#243;meno guarda una relaci&#243;n directa con el grado de obesidad<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a>&#46; Si la ingesta cal&#243;rica excesiva se perpet&#250;a en el tiempo&#44; la acumulaci&#243;n de triglic&#233;ridos se producir&#225; solo mediante hipertrofia de los adipocitos y no mediante hiperplasia&#44; lo que se traduce en una alteraci&#243;n de la regulaci&#243;n de la s&#237;ntesis de citocinas antiinflamatorias y proinflamatorias<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a>&#46; En concreto&#44; algunas de las adipocinas que se sintetizan en mayor medida son el factor de necrosis tumoral alfa &#40;TNF&#945;&#41;&#44; la interleucina-6&#44; la prote&#237;na quimioatrayente de monocitos 1 y el inhibidor del activador del plasmin&#243;geno<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">El TNF&#945; es una prote&#237;na central en la fisiopatolog&#237;a de las artropat&#237;as inflamatorias y la diana terap&#233;utica de muchos tratamientos biol&#243;gicos&#46; Adem&#225;s&#44; tambi&#233;n es un v&#237;nculo entre las enfermedades inmunomediadas&#44; la obesidad y otras condiciones asociadas&#44; como la resistencia a la insulina&#44; la dislipidemia o la aterosclerosis<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a>&#46; Existe evidencia que indica que ciertas intervenciones&#44; como la dieta o la actividad f&#237;sica&#44; que conducen a una disminuci&#243;n del peso corporal&#44; tambi&#233;n pueden disminuir los niveles de TNF&#945;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a>&#46; Existe adem&#225;s una relaci&#243;n establecida entre la obesidad y la APs&#46; Esta relaci&#243;n es bidireccional&#58; la obesidad implica la s&#237;ntesis de citocinas como el TNF&#945; o factor de crecimiento endotelial vascular&#44; que promueven el comienzo de artritis en sujetos predispuestos&#44; de hecho&#44; el exceso de peso corporal se considera un factor de riesgo independiente de APs&#46; Por otro lado&#44; las citocinas proinflamatorias que participan en la fisiopatolog&#237;a de la APs favorecer la obesidad<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">La PCR y la VSG son 2 reactantes de fase aguda que se utilizan habitualmente en la pr&#225;ctica diaria del reumat&#243;logo&#46; La PCR se asocia con un peor control de la glucemia y la presi&#243;n arterial&#59; y suele estar m&#225;s elevada en fumadores<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a>&#46; La VSG es un predictor independiente del riesgo cardiovascular&#44; que puede ser &#250;til para evaluar el riesgo incluso en una poblaci&#243;n de no alto riesgo<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a>&#46; Tanto la VSG como la PCR se asocian con un IMC y un per&#237;metro abdominal mayores<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; La obesidad conduce a niveles m&#225;s altos de estos reactantes de fase aguda&#44; lo que se debe en parte al TNF&#945; y a la interleucina-<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a>&#46; Esta relaci&#243;n entre el IMC y los reactantes de fase aguda est&#225; presente tanto en sujetos con APs o artritis reumatoide &#40;AR&#41; como sin ella<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a>&#44; lo que indica que un exceso de PCR en individuos obesos no implica necesariamente una mayor actividad de la enfermedad<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a>&#46; Nuestros resultados reflejan que existe una asociaci&#243;n entre los datos antropom&#233;tricos y los reactantes de fase aguda&#44; pero no hay tal relaci&#243;n con la actividad de la enfermedad medida por DAPSA ni MDA&#46; Por tanto&#44; nuestros resultados sugieren que en pacientes obesos unos valores m&#225;s altos de PCR y&#47;o VSG no implican necesariamente una mayor actividad de la enfermedad&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">La obesidad tambi&#233;n se asocia con una peor respuesta al tratamiento tanto en la AR como en la APs&#44; especialmente si el paciente est&#225; recibiendo tratamiento con anti-TNF&#945;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a>&#46; Sin embargo&#44; los mecanismos subyacentes de este fen&#243;meno no son del todo bien conocidos&#46; Una de las posibles explicaciones es que la producci&#243;n de TNF&#945; e interleucina-6 por los adipocitos en situaciones de obesidad&#44; junto con la propia actividad de la enfermedad&#44; crean una mayor carga inflamatoria<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a>&#46; Tambi&#233;n existe una hip&#243;tesis que sostiene que los pacientes obesos tienen un mayor volumen de distribuci&#243;n&#44; generando un menor pico del f&#225;rmaco en sangre&#44; lo que se relaciona con una menor efectividad y&#44; adem&#225;s&#44; facilita la s&#237;ntesis de anticuerpos antif&#225;rmaco<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Dadas las implicaciones del TNF&#945; en las enfermedades metab&#243;licas&#44; es l&#243;gico suponer que las terapias biol&#243;gicas pueden tener un impacto positivo en el perfil metab&#243;lico del paciente&#44; aunque no existe una evidencia clara al respecto&#46; Algunos estudios han encontrado que los individuos tratados con infliximab&#44; adalimumab o etanercept muestran una tendencia a un menor per&#237;metro abdominal&#44; a una disminuci&#243;n de la resistencia a la insulina&#44; niveles de triglic&#233;ridos y glucemia basal&#59; y a unos niveles m&#225;s altos de HDL<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">11&#44;12</span></a>&#46; Estos hallazgos parecen ser similares en otras enfermedades inmunomediadas&#44; como la AR<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a>&#44; la psoriasis<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> o la enfermedad inflamatoria intestinal<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a>&#44; destacando as&#237; el papel del TNF&#945; como intermediario entre las enfermedades inflamatorias y metab&#243;licas&#46; Sin embargo&#44; existen otros estudios que no encuentran esta relaci&#243;n&#44; al menos en pacientes con APs<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a>&#46; El uso de metotrexato se ha asociado con una mejora del perfil lip&#237;dico y la glucemia basal&#44; pero no existe tal relaci&#243;n con la resistencia a la insulina<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a>&#46; En cualquier caso&#44; el beneficio relacionado con la enfermedad metab&#243;lica&#44; si lo hubiera&#44; parece ser m&#225;s evidente en los pacientes tratados con anti-TNF que en los que reciben metotrexato<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a>&#46; Con respecto a las enfermedades cardiovasculares&#44; el tratamiento con anti-TNF podr&#237;a reducir el riesgo de eventos cardiovasculares&#44; aunque esta asociaci&#243;n es m&#225;s evidente en los pacientes con AR<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> que en los pacientes con psoriasis o APs<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">28&#44;29</span></a>&#46; Nuestros datos no muestran relaci&#243;n entre el tratamiento anti-TNF&#945; y las enfermedades metab&#243;licas&#44; probablemente por el protocolo de recogida de datos&#44; pero s&#237; que indican que el uso de FAME-B podr&#237;a reducir la prevalencia de eventos cardiovasculares al compararlos con aquellos que reciben tratamiento con terapias convencionales&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Entre las limitaciones de nuestro trabajo se encuentran las propias de un estudio transversal&#46; El hecho de no encontrar una relaci&#243;n con el estado metab&#243;lico podr&#237;a deberse a que solo se tuvo en cuenta si al paciente estaba diagnosticado de alguna de las enfermedades metab&#243;licas incluidas en el estudio o no&#46; No se registraron los valores de presi&#243;n arterial&#44; colesterol&#44; triglic&#233;ridos&#44; glucemia o &#225;cido &#250;rico&#46; Por tanto&#44; podr&#237;a existir alguna relaci&#243;n entre el perfil metab&#243;lico y el tratamiento recibido&#59; y no haberse encontrado debido al protocolo de recolecci&#243;n de datos&#46; Las correlaciones que hemos obtenido tienen un grado de asociaci&#243;n bajo o muy bajo&#44; probablemente debido a la situaci&#243;n basal de los pacientes en cuanto a actividad de la enfermedad y valores de PCR y VSG &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusiones</span><p id="par0155" class="elsevierStylePara elsevierViewall">Existe una menor prevalencia de entesitis y eventos cardiovasculares&#44; y menores niveles de PCR y VSG en el grupo de pacientes tratados con terapias biol&#243;gicas en comparaci&#243;n con los que han recibido tratamiento con metotrexato u otras terapias convencionales&#46; Nuestros resultados son consistentes con otros trabajos que encuentran la entesitis como factor de riesgo cardiovascular independiente en la APs&#46; Por tanto&#44; nuestros datos refuerzan la evidencia disponible que sugiere que el tratamiento con anti-TNF&#945; puede reducir el riesgo cardiovascular en pacientes con APs&#46; Esto podr&#237;a deberse a una mayor disminuci&#243;n de la carga inflamatoria en comparaci&#243;n con las terapias convencionales&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Nuestros resultados no muestran ninguna asociaci&#243;n entre las terapias biol&#243;gicas y un perfil metab&#243;lico favorable&#44; aunque esto podr&#237;a deberse al protocolo de recogida de datos&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Los datos de nuestra serie tambi&#233;n indican que pueden existir niveles m&#225;s altos de PCR y VSG en individuos obesos&#44; sin que ello implique necesariamente una mayor actividad de la enfermedad&#44; por lo que la valoraci&#243;n de este tipo de pacientes deber&#237;a ser m&#225;s exhaustiva&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicto de intereses</span><p id="par0170" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Antecedentes y objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La artritis psori&#225;sica se acompa&#241;a de una serie de comorbilidades cardiovasculares y metab&#243;licas&#46; La obesidad transcribe un estado de inflamaci&#243;n sist&#233;mica de bajo grado&#46; Adem&#225;s&#44; es un predictor negativo de la respuesta al tratamiento&#46; Nuestro objetivo es evaluar si existen interacciones entre el estado metab&#243;lico&#44; los par&#225;metros inflamatorios y la actividad de la enfermedad&#46; Tambi&#233;n queremos comprobar si las enfermedades metab&#243;licas o cardiovasculares tienen alguna asociaci&#243;n con la reducci&#243;n de la carga inflamatoria mediante el tratamiento de la enfermedad&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hemos realizado un estudio descriptivo transversal de 160 pacientes con artritis psori&#225;sica&#46; Se recogieron variables sociodemogr&#225;ficas&#44; cl&#237;nicas y anal&#237;ticas&#46; Tambi&#233;n se registr&#243; la presencia de dactilitis y entesitis&#44; el HAQ&#44; DAPSA y si se cumplen o no los criterios MDA&#46; La prueba de chi-cuadrado y la H de Kruskall Wallis se utilizaron para realizar comparaciones&#44; considerando p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 como estad&#237;sticamente significativo&#46; Para establecer correlaciones&#44; se utiliz&#243; el coeficiente de correlaci&#243;n de Pearson&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El IMC y el per&#237;metro abdominal se correlacionan con la PCR y la VSG &#40;significaci&#243;n<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; aunque la fuerza de correlaci&#243;n es baja &#40;Pearson<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;4&#41;&#44; pero no con DAPSA o con cumplir los criterios de MDA&#46; El uso de terapias biol&#243;gicas se asocia con una menor prevalencia de eventos cardiovasculares &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;047&#59; OR&#58; 0&#44;12&#59; IC 95&#37;&#58; 0&#44;01-0&#44;9&#41; y de entesitis &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#59; OR&#58; 0&#44;3&#59; IC 95&#37;&#58; 0&#44;16-0&#44;56&#41;&#46; Tambi&#233;n se asocia a unos niveles normales de PCR &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;029&#59; OR&#58; 0&#44;25&#59; IC 95&#37;&#58; 0&#44;07-0&#44;87&#41; y VSG &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;024&#59; OR&#58; 0&#44;36&#59; IC 95&#37;&#58; 0&#44;16-0&#44;82&#41; cuando se compara con las terapias convencionales&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discusi&#243;n y conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El tratamiento anti-TNF&#945; podr&#237;a reducir el riesgo cardiovascular en pacientes con artritis psori&#225;sica&#46; Puede haber niveles m&#225;s altos de PCR y VSG en personas obesas sin que esto implique necesariamente una mayor actividad de la enfermedad&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0005"
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            "titulo" => "Material y m&#233;todo"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background and objetives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Psoriatic arthritis is accompained by several cardiometabolic comorbidities&#46; Obesity causes a low-grade systemic inflammation and is a negative predictor of treatment response&#46; We wanted to evaluate if there are interactions between metabolic status&#44; inflammatory parameters and disease activity&#59; and whether metabolic or cardiovascular diseases have any association with the reduction of the inflammatory burden by treating the psoriatic arthritis&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We have carried out a cross-sectional descriptive study of 160 patients with psoriatic arthritis&#46; Sociodemographic&#44; clinical and analytical variables were collected&#44; as well as the presence of dactylitis and enthesitis&#59; and HAQ&#44; DAPSA and Minimal Disease Activity criteria&#46; Chi-square test and the H of Kruskall Wallis were used to carry out comparisons&#44; considering <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 as statistically significant&#46; To establish correlations&#44; Pearson correlation coefficient was used&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">BMI and waist circumference correlate with CRP and ESR &#40;significance&#58; &#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; although the correlation strenght is low &#40;Pearson<span class="elsevierStyleHsp" style=""></span>&#60;&#46;4&#41;&#44; but there is no such relationship with DAPSA or meeting MDA criteria&#46; Using biologic therapies is associated with a lower prevalence of cardiovascular events &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;047&#59; OR&#58; 0&#46;12&#44; 95&#37; CI&#58; 0&#46;01-0&#46;9&#41; and enthesitis &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;008&#59; OR&#58; 0&#46;3&#44; CI 95&#37;&#58; 0&#46;16-0&#46;56&#41;&#59; and normal levels of CRP &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;029&#59; OR&#58; 0&#46;25&#44; 95&#37; CI&#58; 0&#46;07-0&#46;87&#41; and ESR &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;024&#59; OR&#58; 0&#46;36&#44; 95&#37; CI&#58; 0&#46;16-0&#46;82&#41; when comparing to conventional therapies&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion and conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Anti-TNF&#945; treatment could reduce cardiovascular risk in patients with psoriatic arthritis&#46; There may be higher levels of CRP and ESR in obese individuals without this necessarily implying higher disease activity&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Mixto</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">37 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Dactilitis</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">65 &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Entesitis</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">40 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Interfal&#225;ngicas distales</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">40 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Uve&#237;tis</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Erosiones</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">19 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">PCR</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;0&#44;10-0&#44;60&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">VSG</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;3&#44;00-15&#44;00&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">HAQ</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;0&#44;00-0&#44;63&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">DAPSA</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;2&#44;00-12&#44;00&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">MDA</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">54 &#40;34&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">106 &#40;66&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Sin tratamiento</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;13&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">FAME-C</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Metotrexato&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43 &#40;26&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Leflunomida&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;3&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Sulfasalazina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">FAME-B</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>iTNF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67 &#40;41&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Ustekinumab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;11&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Secukinumab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;2&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas de la poblaci&#243;n</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Tabla 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">En negrita&#44; datos estad&#237;sticamente significativos&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MDA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IMC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pearson&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;792&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;192&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;365&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;262&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;114&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#8722;0&#44;085&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Significaci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;000</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;015</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;000</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;151&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;287&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Per&#237;metro abdominal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pearson&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;192&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;212&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;153&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;094&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Significaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;015</span>&nbsp;\t\t\t\t\t\t\n
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