was read the article
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elsevierViewall">The survival curves determined using the Kaplan-Meier survival analysis for herpes zoster among SLE patients and non-SLE patients during the three-year follow-up period.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Hsin-Hua Chen, Yi-Ming Chen, Tzeng-Ji Chen, Joung-Liang Lan, Ching-Heng Lin, Der-Yuan Chen" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Hsin-Hua" "apellidos" => "Chen" ] 1 => array:2 [ "nombre" => "Yi-Ming" "apellidos" => "Chen" ] 2 => array:2 [ "nombre" => "Tzeng-Ji" "apellidos" => "Chen" ] 3 => array:2 [ "nombre" => "Joung-Liang" "apellidos" => "Lan" ] 4 => array:2 [ "nombre" => "Ching-Heng" "apellidos" => "Lin" ] 5 => array:2 [ "nombre" => "Der-Yuan" "apellidos" => "Chen" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222020099?idApp=UINPBA00004N" "url" => "/18075932/0000006600000007/v1_202212011408/S1807593222020099/v1_202212011408/en/main.assets" ] 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true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ludmila Tais Yazbek Gomieiro, Andréia Nascimento, Luciana Kase Tanno, Rosana Agondi, Jorge Kalil, Pedro Giavina-Bianchi" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Ludmila Tais Yazbek" "apellidos" => "Gomieiro" ] 1 => array:2 [ "nombre" => "Andréia" "apellidos" => "Nascimento" ] 2 => array:2 [ "nombre" => "Luciana Kase" "apellidos" => "Tanno" ] 3 => array:2 [ "nombre" => "Rosana" "apellidos" => "Agondi" ] 4 => array:2 [ "nombre" => "Jorge" "apellidos" => "Kalil" ] 5 => array:2 [ "nombre" => "Pedro" "apellidos" => "Giavina-Bianchi" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222020075?idApp=UINPBA00004N" "url" => "/18075932/0000006600000007/v1_202212011408/S1807593222020075/v1_202212011408/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">CLINICAL SCIENCE</span>" "titulo" => "Intestinal microsporidiosis: a hidden risk in rheumatic disease patients undergoing anti-tumor necrosis factor therapy combined with disease-modifying anti-rheumatic drugs?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1171" "paginaFinal" => "1175" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Nadia Emi Aikawa, Aline de Oliveira Twardowsky, Jozélio Freire de Carvalho, Clovis A Silva, Ivan Leonardo Avelino França e Silva, Ana Cristina de Medeiros Ribeiro, Carla Gonçalves Schain Saad, Julio César Bertacini Moraes, Roberto Acayaba de Toledo, Eloísa Bonfá" "autores" => array:10 [ 0 => array:4 [ "nombre" => "Nadia Emi" "apellidos" => "Aikawa" "email" => array:1 [ 0 => "nadia.aikawa@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">I</span>" "identificador" => "aff1" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">II</span>" "identificador" => "aff2" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor1" ] ] ] 1 => array:3 [ "nombre" => "Aline" "apellidos" => "de Oliveira Twardowsky" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">II</span>" "identificador" => "aff2" ] ] ] 2 => array:3 [ "nombre" => "Jozélio Freire" "apellidos" => "de Carvalho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">I</span>" "identificador" => "aff1" ] ] ] 3 => array:3 [ "nombre" => "Clovis A" "apellidos" => "Silva" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">I</span>" "identificador" => "aff1" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">II</span>" "identificador" => "aff2" ] ] ] 4 => array:3 [ "nombre" => "Ivan Leonardo Avelino França e" "apellidos" => "Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">III</span>" "identificador" => "aff3" ] ] ] 5 => array:3 [ "nombre" => "Ana Cristina" "apellidos" => "de Medeiros Ribeiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">I</span>" "identificador" => "aff1" ] ] ] 6 => array:3 [ "nombre" => "Carla Gonçalves Schain" "apellidos" => "Saad" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">I</span>" "identificador" => "aff1" ] ] ] 7 => array:3 [ "nombre" => "Julio César Bertacini" "apellidos" => "Moraes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">I</span>" "identificador" => "aff1" ] ] ] 8 => array:3 [ "nombre" => "Roberto Acayaba" "apellidos" => "de Toledo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">IV</span>" "identificador" => "aff4" ] ] ] 9 => array:3 [ "nombre" => "Eloísa" "apellidos" => "Bonfá" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">I</span>" "identificador" => "aff1" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Division of Rheumatology, CEDMAC Unit, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP/Brazil." "etiqueta" => "I" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "Pediatric Reumatology Unit, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP/Brazil." "etiqueta" => "II" "identificador" => "aff2" ] 2 => array:3 [ "entidad" => "Division of Infectology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP/Brazil." "etiqueta" => "III" "identificador" => "aff3" ] 3 => array:3 [ "entidad" => "Division of Rheumatology, CEDMAC Unit, Faculdade de Medicina de São José do Rio Preto, SP/Brazil." "etiqueta" => "IV" "identificador" => "aff4" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Tel.: 005511-3069-8563, Fax: 005511-3069-8503" ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Microsporidia has emerged in recent years as an opportunistic infectious agent with a ubiquitous distribution.<a class="elsevierStyleCrossRefs" href="#bib1">1–4</a> The clinical manifestations of this infection vary widely, from none (asymptomatic) to non-bloody watery diarrhea, abdominal cramps, weight loss, and disseminated disease, especially in immunosuppressed subjects.<a class="elsevierStyleCrossRefs" href="#bib2">2–4</a></p><p id="para20" class="elsevierStylePara elsevierViewall">This parasitological disease primarily affects immunosuppressed patients,<a class="elsevierStyleCrossRefs" href="#bib1">1–4</a> particularly those with human immunodeficiency virus (HIV), malignancies and diabetes mellitus, as well as patients post heart-lung, liver, and renal transplantations.<a class="elsevierStyleCrossRefs" href="#bib1">1,2</a> In addition, this infection also occurs in patients undergoing immunosuppressive drug treatment.<a class="elsevierStyleCrossRefs" href="#bib2">2,4</a></p><p id="para30" class="elsevierStylePara elsevierViewall">In fact, patients with rheumatic diseases who are taking disease-modifying anti-rheumatic drugs (DMARD) and anti-tumor necrosis factor (TNF) therapy have a high risk for general infections,<a class="elsevierStyleCrossRefs" href="#bib5">5–7</a> including intestinal pathogenic parasite infestations such as <span class="elsevierStyleItalic">Strongyloides stercoralis</span>.<a class="elsevierStyleCrossRefs" href="#bib8">8,9</a> However, to our knowledge, there are no data regarding the risk of microsporidiosis in these patients.<a class="elsevierStyleCrossRefs" href="#bib10">10–13</a></p><p id="para40" class="elsevierStylePara elsevierViewall">Therefore, the objective of this study was to evaluate the frequency and clinical significance of microsporidiosis in patients with rheumatic diseases who are undergoing anti-TNF/DMARD treatment compared to an age- and socio-economic condition-matched healthy population.</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">MATERIALS AND METHODS</span><p id="para50" class="elsevierStylePara elsevierViewall">We evaluated 89 consecutive patients at our hospital who were diagnosed with rheumatoid arthritis (RA) (American College of Rheumatology criteria),<a class="elsevierStyleCrossRef" href="#bib14">14</a> ankylosing spondylitis (AS) (New York criteria),<a class="elsevierStyleCrossRef" href="#bib15">15</a> or psoriatic arthritis (PsA) (European spondyloarthropathy Study Group – ESSG criteria and Moll and Wright classification).<a class="elsevierStyleCrossRef" href="#bib16">16</a> All patients were undergoing anti-TNF therapy (adalimumab, etanercept, or infliximab) combined with DMARDs. The control group included 92 healthy employees of our hospital who were matched by age and socio-economic status. Prior to this study, no specific routine existed in our Infusion Center with regard to stool examination for parasites and fecal leukocytes before anti-TNF therapy. The prophylactic use of anti-helminthic drugs was recommended for patients under concomitant glucocorticoid therapy.</p><p id="para60" class="elsevierStylePara elsevierViewall">This study was approved by the local ethics committee, and informed consent was obtained from each participant or his or her legal guardian.</p><p id="para70" class="elsevierStylePara elsevierViewall">Demographic data, the number of school years attended, and the socio-economic status (according to <span class="elsevierStyleItalic">Associação Brasileira dos Institutos de Pesquisa de Mercados</span>)<a class="elsevierStyleCrossRef" href="#bib17">17</a> were recorded. Background information and parasitosis symptoms in patients and control participants were acquired via interview and included the following: general (loss of appetite, weight loss, and adynamia), gastrointestinal (abdominal pain, abdominal distension, flatulence, diarrhea, dysentery, tenesmus, obstipation, nausea, vomiting, hematochezia, and worm elimination), cutaneous (exanthema), and pulmonary manifestations (wheezing, thoracic pain, and hemoptysis).</p><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">Disease activity and laboratory evaluation of rheumatic diseases</span><p id="para80" class="elsevierStylePara elsevierViewall">Disease activity was evaluated by the following: the duration of morning stiffness, the number of swollen and/or painful joints, and the disease activity score (DAS28) for RA patients<a class="elsevierStyleCrossRef" href="#bib18">18</a> and the number of swollen and/or painful joints and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)<a class="elsevierStyleCrossRef" href="#bib19">19</a> for AS and PsA patients.</p><p id="para90" class="elsevierStylePara elsevierViewall">The laboratory parameters assessed included the erythrocyte sedimentation rate (ESR) according to Westergreen (mm/<span class="elsevierStyleSup">1st</span> hour) and C-reactive protein (CRP) level determined by nephelometry (mg/L). Data concerning current treatment with prednisone, DMARDs, anti-TNF and immunosuppressive drugs (methotrexate, azathioprine, leflunomide, chloroquine, sulfasalazine and/or cyclosporine) were collected.</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">Parasitological assessment</span><p id="para100" class="elsevierStylePara elsevierViewall">Three stool samples were collected from rheumatic disease patients and control subjects on different days and placed into plastic vials without preservatives. The stool samples were microscopically analyzed for the detection of protozoan oocysts, cysts, helminth eggs, and larvae by a qualified technician blinded to the groups using the techniques described by Faust et al, Rugai and Lutz (modified), and Hoffman, Pons and Janer.<a class="elsevierStyleCrossRef" href="#bib20">20</a></p><p id="para110" class="elsevierStylePara elsevierViewall">Microsporidia positivity was defined as the isolation of at least one parasite using the GRAM-Chromotrope<a class="elsevierStyleCrossRef" href="#bib21">21</a> technique.</p><p id="para120" class="elsevierStylePara elsevierViewall">Intestinal coccidia were evaluated by the GRAM-Chromotrope<a class="elsevierStyleCrossRef" href="#bib21">21</a> technique; Leishman staining<a class="elsevierStyleCrossRef" href="#bib22">22</a> was used to identify <span class="elsevierStyleItalic">Blastocystis hominis</span> and fecal leukocytes; the Kinyoun procedure<a class="elsevierStyleCrossRef" href="#bib23">23</a> and capture enzyme-linked immunosorbent assay (capture ELISA) were used to detect <span class="elsevierStyleItalic">Cryptosporidium sp</span>., <span class="elsevierStyleItalic">Cyclospora cayetanensis,</span> and <span class="elsevierStyleItalic">Isospora belli;</span> and Kato-Katz was used to detect <span class="elsevierStyleItalic">Schistosoma mansoni</span>.<a class="elsevierStyleCrossRef" href="#bib24">24</a> Coproculture was also performed using SS agar, MacConkey agar or Karmali plate agar.<a class="elsevierStyleCrossRef" href="#bib25">25</a></p><p id="para130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Giardia lamblia, Strongyloides stercoralis, Ancilostoma duodenali, Ascaris lumbricoides, Entamoeba histolytica, Microsporidia</span> (positive stool leukocytes), <span class="elsevierStyleItalic">Entamoeba dispar, Dientamoeba fragilis, Cryptosporidium parvum, Cyclospora cayetanensis, Isospora belli,</span> and <span class="elsevierStyleItalic">Blastocystis hominis</span> (positive stool leukocytes) were defined as pathogenic parasites in immunocompromised patients.<a class="elsevierStyleCrossRef" href="#bib1">1</a> All participants with positive pathogenic parasites were treated with the appropriate recommended antiparasitic drugs.<a class="elsevierStyleCrossRef" href="#bib26">26</a></p></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">Statistical analysis</span><p id="para140" class="elsevierStylePara elsevierViewall">Results are presented as the mean ± standard deviation or the median (range) for continuous variables and the number (%) for categorical variables. Continuous variables were compared using the <span class="elsevierStyleItalic">t</span> test and the Mann Whitney test to evaluate differences between patients with and without intestinal microsporidia and other parasitoses. For categorical variables, differences in proportions were assessed by Fisher's exact test. For all statistical tests, significance was set at a <span class="elsevierStyleItalic">p</span>-value <0.05.</p></span></span><span id="cesec60" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle110">RESULTS</span><p id="para150" class="elsevierStylePara elsevierViewall">A total of 89 patients with rheumatic diseases (47 RA, 31 AS and 11 PsA) and 92 healthy control subjects were included in this study. The two groups were comparable with regard to the mean current age (47.2±10.9 <span class="elsevierStyleItalic">vs.</span> 43.8±14.3 years, respectively; <span class="elsevierStyleItalic">p</span> = 0.094), percentage who were Caucasian (80 <span class="elsevierStyleItalic">vs.</span> 73%, respectively; <span class="elsevierStyleItalic">p</span> = 0.3) and socio-economic distribution, with a similar predominance of the middle and lowest Brazilian socio-economic classes (C, D or E)<a class="elsevierStyleCrossRef" href="#bib17">17</a> based on scholarity and ownership of household items (84 <span class="elsevierStyleItalic">vs.</span> 82%, respectively; <span class="elsevierStyleItalic">p</span> = 0.7). There were a greater proportion of females in the control group than in the patient group (93 <span class="elsevierStyleItalic">vs.</span> 62%, respectively; <span class="elsevierStyleItalic">p</span><0.0001). The mean disease duration for all patients was 15.5±8.6 years.</p><span id="cesec70" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle120">Intestinal parasites</span><p id="para160" class="elsevierStylePara elsevierViewall">The overall frequency of pathogenic parasites was similar in both the patient and control groups (63 <span class="elsevierStyleItalic">vs.</span> 58%, respectively; <span class="elsevierStyleItalic">p</span> = 0.54). Positive tests for microsporidia were significantly higher in all types of rheumatic disease patients compared with the control subjects (38 <span class="elsevierStyleItalic">vs.</span> 4%, respectively; <span class="elsevierStyleItalic">p</span><0.0001), and microsporidia plus positive fecal leukocytes were also more frequently detected in patients than in control subjects (31 <span class="elsevierStyleItalic">vs.</span> 4%, respectively; <span class="elsevierStyleItalic">p</span><0.0001). Of note, 81.6% of the positive microsporidia patients had concomitant fecal leukocytes. In contrast, no differences were detected for other pathogenic parasites (<span class="elsevierStyleItalic">Entamoeba histolytica/dispar, Dientamoeba fragilis, Giardia lamblia, Cryptosporidium parvum, Cyclospora cayetanensis, Isospora belli, Ancilostoma duodenale, Ascaris lumbricoides,</span> and <span class="elsevierStyleItalic">Blastocystis hominis</span> with leukocytes) and non-pathogenic parasites (<span class="elsevierStyleItalic">Endolimax nana, Entamoeba coli,</span> and <span class="elsevierStyleItalic">Entamoeba hartmanni</span>) (<span class="elsevierStyleItalic">p</span>>0.05; <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>). Among the 28 patients with microsporidia and positive stool leukocytes, 36% had other concomitant pathogenic parasites, particularly <span class="elsevierStyleItalic">Blastocystis hominis</span> [8/28 (29%) patients]; however, no association of microsporidia and <span class="elsevierStyleItalic">Blatocystis hominis</span> was observed (<span class="elsevierStyleItalic">p</span> = 0.28). Regarding the prevalence of pathogenic parasites in each disease compared to the control group, microsporidiosis was higher in RA (32 <span class="elsevierStyleItalic">vs.</span> 4%, respectively; <span class="elsevierStyleItalic">p</span><0.0001), AS (45 <span class="elsevierStyleItalic">vs.</span> 4%, respectively; <span class="elsevierStyleItalic">p</span><0.0001) and PsA patients (40 <span class="elsevierStyleItalic">vs.</span> 4%, respectively; <span class="elsevierStyleItalic">p</span><0.0001). Moreover, there were no statistical differences in microsporidia positivity between the specific diseases (RA <span class="elsevierStyleItalic">vs.</span> AS and PsA; AS <span class="elsevierStyleItalic">vs.</span> PsA; all <span class="elsevierStyleItalic">p</span>>0.05). <span class="elsevierStyleItalic">Giardia lamblia</span> was significantly more common in AS patients <span class="elsevierStyleItalic">vs.</span> control subjects (10% <span class="elsevierStyleItalic">vs.</span> 0%, respectively; <span class="elsevierStyleItalic">p</span> = 0.0149), whereas no differences were observed for the other pathogenic parasites (<span class="elsevierStyleItalic">p</span>>0.05).</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="para170" class="elsevierStylePara elsevierViewall">Disease activity parameters at the study onset were alike in patients with and without microsporidia infections for all diseases (RA, AS, and PsA) (<span class="elsevierStyleItalic">p</span>>0.05). The analysis of the duration of anti-TNF/DMARD therapy showed no statistical difference between patients with and without microsporidia infection (<span class="elsevierStyleItalic">p</span> = 0.55). The frequencies of glucocorticoid use in patients with and without microsporidiosis [44% (95% IC 0.27-0.62) <span class="elsevierStyleItalic">vs.</span> 64% (95% IC 0.49-0.76); <span class="elsevierStyleItalic">p</span> = 0.08] were alike, as was the number of DMARDs used (<a class="elsevierStyleCrossRef" href="#tbl2">Table 2</a>).</p><elsevierMultimedia ident="tbl2"></elsevierMultimedia><p id="para180" class="elsevierStylePara elsevierViewall">No differences were detected in the frequencies of other infections that required antibiotic therapy in patients with and without microsporidiosis, such as acute lower respiratory infection (2.9 <span class="elsevierStyleItalic">vs.</span> 14.5%, respectively; <span class="elsevierStyleItalic">p</span> = 0.14), urinary tract infection (29.4 <span class="elsevierStyleItalic">vs.</span> 30.9%, respectively; <span class="elsevierStyleItalic">p</span> = 1.0) cutaneous infection (20.6 <span class="elsevierStyleItalic">vs.</span> 23.6%, respectively; <span class="elsevierStyleItalic">p</span> = 0.8) and tuberculosis (2.9 <span class="elsevierStyleItalic">vs.</span> 1.8%, respectively; <span class="elsevierStyleItalic">p</span> = 1.0).</p><p id="para190" class="elsevierStylePara elsevierViewall">The comparison of rheumatic disease patients with and without microsporidiosis revealed that 85.4% of the patients had gastrointestinal symptoms such as diarrhea (19%), abdominal pain (22%), and weight loss (11%), but these symptoms occurred just as frequently in patients with and without this infection (<span class="elsevierStyleItalic">p</span>>0.05). Other signs and symptoms related to parasitoses were also comparable in the two groups, with the exception of abdominal distension (<span class="elsevierStyleItalic">p</span> = 0.013) and adynamia (<span class="elsevierStyleItalic">p</span> = 0.009), both of which occurred less often in patients with microsporidiosis (<a class="elsevierStyleCrossRef" href="#tbl3">Table 3</a>). No patient or control group had a disseminated infection.</p><elsevierMultimedia ident="tbl3"></elsevierMultimedia></span></span><span id="cesec80" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle130">DISCUSSION</span><p id="para200" class="elsevierStylePara elsevierViewall">This study is the first to identify a high frequency of microsporidia infections associated with intestinal mucosa disruption in rheumatic disease patients undergoing anti-TNF and DMARD therapies.</p><p id="para210" class="elsevierStylePara elsevierViewall">The study design has several advantages, including the inclusion of patients with well-established rheumatic disease criteria.<a class="elsevierStyleCrossRefs" href="#bib14">14–16</a> In addition, the Gram-Chromotrope stain methodology applied in this study is considered to be one of the most specific detection techniques with the best sensitivity for detecting microsporidia in fluids, including feces.<a class="elsevierStyleCrossRef" href="#bib2">2</a> Moreover, external factors such as socio-economic conditions may influence parasitosis prevalence. For example, the frequency of microsporidia in HIV-infected patients was higher in Venezuela (13.6%), an underdeveloped country, than in Italy (1.8%).<a class="elsevierStyleCrossRefs" href="#bib27">27–28</a> This potential bias was greatly reduced by the matching of our patients with a control group with the same socio-financial distribution. One limitation of our study was the absence of a control group of rheumatic disease patients treated only with DMARDs, due to the impossibility of achieving an adequate matching for disease duration and severity in these patients. In fact, anti-TNF therapy is now being indicated very early for patients with these diseases. There are, however, no data on the frequency of microsporidia infection in rheumatic disease patients without anti-TNF therapy.</p><p id="para220" class="elsevierStylePara elsevierViewall">Microsporidia has emerged as an important cause of infectious complications in severely immunocompromised patients with HIV, recipients of solid organ transplant and patients with hematological malignancies.<a class="elsevierStyleCrossRefs" href="#bib1">1–3</a> Cell-mediated immunity appears to be critical for protection against microsporidia through the T helper cell 1 (Th1) cytokine response.<a class="elsevierStyleCrossRef" href="#bib3">3</a> The importance of a Th1 response in the resistance to microsporidial infection has been demonstrated by <span class="elsevierStyleItalic">in vitro</span> studies showing that knockout animals for Th1 cytokines such as interferon and interleukin-12 could not clear microsporidia infections.<a class="elsevierStyleCrossRef" href="#bib29">29</a> In fact, more severe microsporidia infections were observed in HIV-infected patients with declining CD4+ and CD8+ T-cell numbers.<a class="elsevierStyleCrossRef" href="#bib29">29</a> Accordingly, the inhibition of TNF-alpha, a cytokine well known to be related to the Th1 response,<a class="elsevierStyleCrossRef" href="#bib30">30</a> could possibly facilitate the microsporidia infestation observed in the present study. Moreover, experimental studies have reported a decrease in the specific protective IgG against microsporidia in animals treated with immunosuppressive drugs.<a class="elsevierStyleCrossRef" href="#bib31">31</a> We have confirmed that microsporidia infestation is more prevalent in immunosuppressed patients<a class="elsevierStyleCrossRefs" href="#bib1">1–4</a> and have now extended this observation to rheumatic disease patients undergoing anti-TNF/DMARD treatment.</p><p id="para230" class="elsevierStylePara elsevierViewall">Microsporidiosis and intestinal parasitosis may present with diverse clinical manifestations, depending on the host immune status and the microsporidium species.<a class="elsevierStyleCrossRefs" href="#bib1">1–4</a> Diarrhea and wasting syndromes are the most common complaints;<a class="elsevierStyleCrossRefs" href="#bib1">1–4</a> however, these parasite infections can be asymptomatic. In fact, the parasitosis in our study was frequently associated with gastrointestinal manifestations and concomitant stool leukocytes, indicating a possible intestinal mucosa disruption,<a class="elsevierStyleCrossRef" href="#bib32">32</a> which is a known risk for intestinal dissemination.<a class="elsevierStyleCrossRef" href="#bib33">33</a></p><p id="para240" class="elsevierStylePara elsevierViewall">Infection is a major co-morbidity in rheumatic conditions, and therapies such as conventional DMARDs and anti-TNF are known to enhance the risk of infection.<a class="elsevierStyleCrossRefs" href="#bib34">34,35</a> In this regard, previous reports have suggested that susceptibility to infection may be distinct in different underlying rheumatic diseases. The main explanation for this finding seems to be a disease-associated genetic background and immunosuppressive therapy.<a class="elsevierStyleCrossRefs" href="#bib36">36,37</a> However, in the present study, no difference was observed in microsporidiosis frequency between the specific rheumatic diseases, suggesting that anti-TNF/DMARD treatment is a more relevant risk factor for this infestation than is the specific rheumatic disease itself.</p><p id="para250" class="elsevierStylePara elsevierViewall">We have identified microsporidiosis to be a frequent infection that is associated with mucosal lesions in patients undergoing concomitant anti-TNF/DMARD treatment. This finding supports the notion that the recommendation for the prophylactic use of anti-helminthic drugs in patients on glucocorticoid therapy could be extended to those initiating anti-TNF therapy.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "xpalclavsec1582313" "titulo" => "KEYWORDS" ] 1 => array:2 [ "identificador" => "cesec10" "titulo" => "INTRODUCTION" ] 2 => array:3 [ "identificador" => "cesec20" "titulo" => "MATERIALS AND METHODS" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "cesec30" "titulo" => "Disease activity and laboratory evaluation of rheumatic diseases" ] 1 => array:2 [ "identificador" => "cesec40" "titulo" => "Parasitological assessment" ] 2 => array:2 [ "identificador" => "cesec50" "titulo" => "Statistical analysis" ] ] ] 3 => array:3 [ "identificador" => "cesec60" "titulo" => "RESULTS" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "cesec70" "titulo" => "Intestinal parasites" ] ] ] 4 => array:2 [ "identificador" => "cesec80" "titulo" => "DISCUSSION" ] 5 => array:1 [ "titulo" => "REFERENCES" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-01-12" "fechaAceptado" => "2011-03-21" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "KEYWORDS" "identificador" => "xpalclavsec1582313" "palabras" => array:5 [ 0 => "Microsporidia" 1 => "Parasitosis" 2 => "Anti-TNF" 3 => "Rheumatoid arthritis" 4 => "Ankylosing spondylitis" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">OBJECTIVE:</span><p id="spara60" class="elsevierStyleSimplePara elsevierViewall">Immunosuppressed patients are at risk of microsporidiosis, and this parasitosis has an increased rate of dissemination in this population. Our objective was to evaluate the presence of microsporidiosis and other intestinal parasites in rheumatic disease patients undergoing anti-tumor necrosis factor/disease-modifying anti-rheumatic drug treatment.</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">METHODS:</span><p id="spara70" class="elsevierStyleSimplePara elsevierViewall">Ninety-eight patients (47 with rheumatoid arthritis, 31 with ankylosing spondylitis and 11 with psoriatic arthritis) and 92 healthy control patients were enrolled in the study. Three stool samples and cultures were collected from each subject.</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">RESULTS:</span><p id="spara80" class="elsevierStyleSimplePara elsevierViewall">The frequency of microsporidia was significantly higher in rheumatic disease patients than in control subjects (36 <span class="elsevierStyleItalic">vs.</span> 4%, respectively; <span class="elsevierStyleItalic">p</span><0.0001), as well as in those with rheumatic diseases (32 <span class="elsevierStyleItalic">vs.</span> 4%, respectively; <span class="elsevierStyleItalic">p</span><0.0001), ankylosing spondylitis (45 <span class="elsevierStyleItalic">vs.</span> 4%, respectively; <span class="elsevierStyleItalic">p</span><0.0001) and psoriatic arthritis (40 <span class="elsevierStyleItalic">vs.</span> 4%, respectively; <span class="elsevierStyleItalic">p</span><0.0001), despite a similar social-economic class distribution in both the patient and control groups (<span class="elsevierStyleItalic">p</span> = 0.1153). Of note, concomitant fecal leukocytes were observed in the majority of the microsporidia-positive patients (79.5%). Approximately 80% of the patients had gastrointestinal symptoms, such as diarrhea (26%), abdominal pain (31%) and weight loss (5%), although the frequencies of these symptoms were comparable in patients with and without this infection (<span class="elsevierStyleItalic">p</span>>0.05). Rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis disease activity parameters were comparable in both groups (<span class="elsevierStyleItalic">p</span>>0.05). The duration of anti-tumor necrosis factor/disease-modifying anti-rheumatic drugs and glucocorticoid use were also similar in both groups.</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSION:</span><p id="spara90" class="elsevierStyleSimplePara elsevierViewall">We have documented that microsporidiosis with intestinal mucosa disruption is frequent in patients undergoing concomitant anti-tumor necrosis factor/disease-modifying anti-rheumatic drug therapy. Impaired host defenses due to the combination of the underlying disease and the immunosuppressive therapy is the most likely explanation for this finding, and this increased susceptibility reinforces the need for the investigation of microsporidia and implementation of treatment strategies in this population.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "ceabs10" "titulo" => "OBJECTIVE:" ] 1 => array:2 [ "identificador" => "ceabs20" "titulo" => "METHODS:" ] 2 => array:2 [ "identificador" => "ceabs30" "titulo" => "RESULTS:" ] 3 => array:2 [ "identificador" => "ceabs40" "titulo" => "CONCLUSION:" ] ] ] ] "NotaPie" => array:1 [ 0 => array:1 [ "nota" => "<p class="elsevierStyleNotepara" id="cenpara10"><span class="elsevierStyleBold">Competing interest:</span></p> <p class="elsevierStyleNotepara" id="cenpara20">This study was supported by grants from FAPESP (2009/51897-5 to EB), CNPQ (3300665/2009-1 to JFC, 300248/2008-3 to CAS and 301411/2009-3 to EB), Federico Foundation (to JFC, CAS and EB) and Wyeth (to NEA).</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Results are presented as n (%); DMARDs - disease-modifying anti-rheumatic drugs.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="top" scope="col">Intestinal parasites \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col">Rheumatic disease patients (n = 89) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col">Control subjects (n = 92) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top"><span class="elsevierStyleBold">Pathogenic parasites</span> \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"> \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"> \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"> \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Microsporidia \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="center" valign="top">34 (38) \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="center" valign="top">4 (4) \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="char" valign="top"><0.0001 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Microsporidia with leukocytes \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="center" valign="top">28 (31) \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="center" valign="top">4 (4) \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="char" valign="top"><0.0001 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Entamoeba histolytica/dispar</span> \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="center" valign="top">0 (0) \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="center" valign="top">4 (4) \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="char" valign="top">0.12 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Dientamoeba fragilis</span> \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="center" valign="top">3 (3) \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="center" valign="top">0 (0) \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="char" valign="top">0.12 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Giardia lamblia</span> \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="center" valign="top">3 (3) \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="center" valign="top">0 (0) \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="char" valign="top">0.12 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Strongyloides stercoralis</span> \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="center" valign="top">3 (3) \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="center" valign="top">2 (2) \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="char" valign="top">0.68 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Cryptosporidium parvum</span> \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="center" valign="top">3 (3) \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="center" valign="top">5 (5) \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="char" valign="top">0.72 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Cyclospora cayetanensis</span> \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="center" valign="top">0 (0) \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="center" valign="top">0 (0) \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="char" valign="top">1.0 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Isospora belli</span> \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="center" valign="top">0 (0) \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="center" valign="top">0 (0) \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="char" valign="top">1.0 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Ancilostoma duodenale</span> \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="center" valign="top">1 (1) \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="center" valign="top">0 (0) \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="char" valign="top">0.49 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Ascaris lumbricoides</span> \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="center" valign="top">0 (0) \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="center" valign="top">0 (0) \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="char" valign="top">1.0 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Blastocystis hominis</span> with leukocytes \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="center" valign="top">46 (52) \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="center" valign="top">42 (46) \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="char" valign="top">0.46 \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="left" valign="top"><span class="elsevierStyleBold">Non-pathogenic parasites</span> \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"> \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"> \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"> \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Endolimax nana</span> \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="center" valign="top">17 (19) \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="center" valign="top">25 (27) \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="char" valign="top">0.22 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Entamoeba coli</span> \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="center" valign="top">6 (7) \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="center" valign="top">12 (13) \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="char" valign="top">0.21 \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="left" valign="top" style="border-bottom: 2px solid black"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Entamoeba hartmanni</span> \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="center" valign="top" style="border-bottom: 2px solid black">1 (1) \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="center" valign="top" style="border-bottom: 2px solid black">1 (1) \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="char" valign="top" style="border-bottom: 2px solid black">0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Intestinal parasites in rheumatic disease patients undergoing anti-TNF/DMARD therapies and healthy controls.</p>" ] ] 1 => array:7 [ "identificador" => "tbl2" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="top" scope="col">Parameters \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col">Patients with microsporidia (n = 34) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col">Patients without microsporidia (n = 55) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top"><span class="elsevierStyleBold">Rheumatoid arthritis (n = 47)</span> \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"> \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"> \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"> \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Morning stiffness, minutes \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="center" valign="top">13±17.9 \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="center" valign="top">26.9±43.2 \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="center" valign="top">0.24 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Number of painful joints \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="center" valign="top">6.5±5.8 \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="center" valign="top">11±10 \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="center" valign="top">0.12 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Number of swollen joints \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="center" valign="top">4.8±5.1 \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="center" valign="top">5.1±4.1 \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="center" valign="top">0.83 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>DAS28 \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="center" valign="top">3.8±1.6 \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="center" valign="top">4.6±1.3 \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="center" valign="top">0.10 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ESR, mm/1<span class="elsevierStyleSup">st</span> hour \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="center" valign="top">26.6±26.1 \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="center" valign="top">27.1±15.5 \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="center" valign="top">0.94 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CRP, mg/L \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="center" valign="top">8.49±9.5 \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="center" valign="top">15.4±17.9 \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="center" valign="top">0.19 \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="left" valign="top"><span class="elsevierStyleBold">Ankylosing spondylitis (n = 31)</span> \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"> \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"> \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"> \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Number of painful joints \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="center" valign="top">5.6±13.4 \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="center" valign="top">3.6±4.2 \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="center" valign="top">0.59 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Number of swollen joints \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="center" valign="top">1.4±1.4 \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="center" valign="top">1.7±2.3 \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="center" valign="top">0.68 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>BASDAI \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="center" valign="top">3.48±2.01 \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="center" valign="top">3.47±2.43 \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="center" valign="top">0.99 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ESR, mm/1<span class="elsevierStyleSup">st</span> hour \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="center" valign="top">23±27 \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="center" valign="top">14±16 \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="center" valign="top">0.27 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CRP, mg/L \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="center" valign="top">12.6±14.5 \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="center" valign="top">13.2±21.1 \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="center" valign="top">0.94 \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="left" valign="top"><span class="elsevierStyleBold">Psoriatic arthritis (n = 11)</span> \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"> \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"> \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"> \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Morning stiffness (minutes) \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="center" valign="top">0 (0-20) \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="center" valign="top">17.5 (0-120) \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="center" valign="top">0.14 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Number of painful joints \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="center" valign="top">5 (0-8) \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="center" valign="top">3.5 (0-12) \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="center" valign="top">0.93 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Number of swollen joints \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="center" valign="top">1 (0-2) \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="center" valign="top">1 (0-2) \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="center" valign="top">0.77 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>BASDAI \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="center" valign="top">2.33 (0-6.98) \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="center" valign="top">4.06 (0.27-5.16) \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="center" valign="top">0.48 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ESR, mm/1<span class="elsevierStyleSup">st</span> hour \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="center" valign="top">11.5 (3-76) \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="center" valign="top">23(1-46) \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="center" valign="top">0.73 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CRP, mg/L \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="center" valign="top">2 (0.2-19.6) \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="center" valign="top">6.8 (1.5-32.5) \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="center" valign="top">0.55 \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="left" valign="top"><span class="elsevierStyleBold">Rheumatic patients treated (n = 89)</span> \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"> \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"> \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"> \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anti-TNF and DMARD therapy duration (months) \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="center" valign="top">15±11.7 \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="center" valign="top">13.6±9.7 \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="center" valign="top">0.55 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Glucocorticoid use \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="center" valign="top">15 (44) \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="center" valign="top">35 (64) \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="center" valign="top">0.08 \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="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Methotrexate use \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="center" valign="top">26 (76) \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="center" valign="top">33 (60) \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="center" valign="top">0.17 \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="left" valign="top" style="border-bottom: 2px solid black"><span class="elsevierStyleHsp" style=""></span>Number of DMARDs \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="center" valign="top" style="border-bottom: 2px solid black">1.1±0.7 \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="center" valign="top" style="border-bottom: 2px solid black">0.9±0.7 \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="center" valign="top" style="border-bottom: 2px solid black">0.33 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Disease activity parameters and treatments in patients with rheumatic diseases undergoing anti-TNF and DMARD therapies with and without microsporidia infection.</p>" ] ] 2 => array:7 [ "identificador" => "tbl3" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spara50" class="elsevierStyleSimplePara elsevierViewall">Results are presented as n (%); DMARDs - disease-modifying anti-rheumatic drugs.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="top" scope="col">Clinical manifestations \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col">Patients with microsporidia (n = 34) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col">Patients without microsporidia (n = 55) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">Abdominal pain \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="char" valign="top">10 (29) \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="char" valign="top">10 (18) \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="char" valign="top">0.296 \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="left" valign="top">Diarrhea \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="char" valign="top">10 (29) \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="char" valign="top">7 (13) \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="char" valign="top">0.094 \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="left" valign="top">Weight loss \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="char" valign="top">2 (6) \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="char" valign="top">8 (15) \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="char" valign="top">0.306 \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="left" valign="top">Nausea \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="char" valign="top">8 (24) \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="char" valign="top">14 (25) \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="char" valign="top">1.0 \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="left" valign="top">Vomit \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="char" valign="top">6 (18) \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="char" valign="top">8 (15) \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="char" valign="top">0.768 \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="left" valign="top">Flatulence \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="char" valign="top">6 (18) \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="char" valign="top">19 (35) \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="char" valign="top">0.096 \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="left" valign="top">Dysentery \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="char" valign="top">2 (6) \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="char" valign="top">0 (0) \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="char" valign="top">0.143 \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="left" valign="top">Tenesmus \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="char" valign="top">0 (0) \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="char" valign="top">4 (7) \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="char" valign="top">0.294 \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="left" valign="top">Obstipation \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="char" valign="top">6 (18) \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="char" valign="top">9 (16) \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="char" valign="top">1.0 \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="left" valign="top">Loss of appetite \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="char" valign="top">7 (21) \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="char" valign="top">6 (11) \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="char" valign="top">0.231 \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="left" valign="top">Hematochezia \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="char" valign="top">2 (6) \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="char" valign="top">5 (9) \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="char" valign="top">0.704 \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="left" valign="top">Worm elimination \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="char" valign="top">0 (0) \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="char" valign="top">5 (9) \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="char" valign="top">0.152 \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="left" valign="top">Wheezing \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="char" valign="top">8 (24) \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="char" valign="top">5 (9) \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="char" valign="top">0.072 \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="left" valign="top">Thoracic pain \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="char" valign="top">8 (24) \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="char" valign="top">6 (11) \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="char" valign="top">0.139 \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="left" valign="top">Hemoptysis \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="char" valign="top">2 (6) \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="char" valign="top">2 (4) \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="char" valign="top">0.635 \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="left" valign="top">Exanthema \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="char" valign="top">2 (6) \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="char" valign="top">10 (18) \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="char" valign="top">0.121 \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="left" valign="top">Abdominal distension \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="char" valign="top">2 (6) \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="char" valign="top">15 (27) \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="char" valign="top">0.013 \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="left" valign="top">Adynamia \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="char" valign="top">11 (32) \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="char" valign="top">34 (62) \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="char" valign="top">0.009 \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="left" valign="top">Any gastrointestinal symptom \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="char" valign="top">29 (85) \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="char" valign="top">47 (85) \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="char" valign="top">1.0 \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="left" valign="top" style="border-bottom: 2px solid black">Systemic dissemination \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="char" valign="top" style="border-bottom: 2px solid black">0 (0) \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="char" valign="top" style="border-bottom: 2px solid black">0 (0) \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="char" valign="top" style="border-bottom: 2px solid black">1.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Clinical manifestations in patients with rheumatic diseases undergoing anti-TNF and DMARD therapies with and without microsporidia infection.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical significance of enteric protozoa in the immunosuppressed human population" "autores" => array:1 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2024 November | 7 | 0 | 7 |
2024 October | 42 | 26 | 68 |
2024 September | 43 | 31 | 74 |
2024 August | 63 | 37 | 100 |
2024 July | 46 | 27 | 73 |
2024 June | 43 | 13 | 56 |
2024 May | 41 | 27 | 68 |
2024 April | 50 | 13 | 63 |
2024 March | 56 | 14 | 70 |
2024 February | 82 | 16 | 98 |
2024 January | 49 | 19 | 68 |
2023 December | 12 | 19 | 31 |
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2023 October | 28 | 27 | 55 |
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2023 August | 36 | 11 | 47 |
2023 July | 15 | 21 | 36 |
2023 June | 15 | 13 | 28 |
2023 May | 10 | 2 | 12 |
2023 April | 7 | 1 | 8 |
2023 March | 4 | 4 | 8 |
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