Discrimination of acute lymphoblastic leukemia from systemic-onset juvenile idiopathic arthritis at disease onset

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B) An intermediate cell-proliferation index (Ki-67∼10%) in a G2 neuroendocrine tumor (X400). C) A high cell-proliferation index (Ki-67∼90%) in a G3 neuroendocrine carcinoma (X400)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Bruna Estrozi, Carlos E Bacchi" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Bruna" "apellidos" => "Estrozi" ] 1 => array:2 [ "nombre" => "Carlos E" "apellidos" => "Bacchi" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222023213?idApp=UINPBA00004N" "url" => "/18075932/0000006600000010/v1_202212011334/S1807593222023213/v1_202212011334/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "CLINICAL SCIENCE" "titulo" => "Discrimination of acute lymphoblastic leukemia from systemic-onset juvenile idiopathic arthritis at disease onset" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1665" "paginaFinal" => "1669" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Mirian S Tamashiro, Nádia Emi Aikawa, Lucia Maria A Campos, Lílian Maria Cristofani, Vicente Odone-Filho, Clovis A Silva" "autores" => array:6 [ 0 => array:3 [ "nombre" => "Mirian S" "apellidos" => "Tamashiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "I" "identificador" => "aff1" ] ] ] 1 => array:3 [ "nombre" => "Nádia Emi" "apellidos" => "Aikawa" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "I" "identificador" => "aff1" ] 1 => array:2 [ "etiqueta" => "III" "identificador" => "aff3" ] ] ] 2 => array:3 [ "nombre" => "Lucia Maria A" "apellidos" => "Campos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "I" "identificador" => "aff1" ] ] ] 3 => array:3 [ "nombre" => "Lílian Maria" "apellidos" => "Cristofani" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "II" "identificador" => "aff2" ] ] ] 4 => array:3 [ "nombre" => "Vicente" "apellidos" => "Odone-Filho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "II" "identificador" => "aff2" ] ] ] 5 => array:4 [ "nombre" => "Clovis A" "apellidos" => "Silva" "email" => array:1 [ 0 => "clovis.silva@icr.usp.br" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "I" "identificador" => "aff1" ] 1 => array:2 [ "etiqueta" => "III" "identificador" => "aff3" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor1" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Pediatric Rheumatology Unit of Instituto da Criança of Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil." "etiqueta" => "I" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "Pediatric Oncology Unit of Instituto da Criança of Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil." "etiqueta" => "II" "identificador" => "aff2" ] 2 => array:3 [ "entidad" => "Division of Rheumatology of Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil." "etiqueta" => "III" "identificador" => "aff3" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Tel.: 00 55 11 26618563" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig2" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 349 "Ancho" => 442 "Tamanyo" => 23359 ] ] "descripcion" => array:1 [ "en" => "The Kaplan-Meier overall survival curves between the whole group of leukemia patients (n = 190) and leukemia patients with limb pain (n = 40) (p = 0.4875)." ] ] ] "textoCompleto" => "INTRODUCTIONAcute lymphoblastic leukemia is the most prevalent cancer in children and adolescents<a class="elsevierStyleCrossRefs" href="#bib1">1,2</a> and is the most frequent malignant neoplasm associated with musculoskeletal complaints at disease onset.<a class="elsevierStyleCrossRefs" href="#bib3">3–9</a> The main clinical osteoarticular manifestations in early leukemia include limb pain, nighttime pain, arthralgia, and arthritis.<a class="elsevierStyleCrossRefs" href="#bib4">4–9</a> Moreover, pediatric leukemia may develop clinical features and laboratory alterations that mimic rheumatic diseases, in particular systemic-onset juvenile idiopathic arthritis (also known as juvenile rheumatoid arthritis).<a class="elsevierStyleCrossRefs" href="#bib7">7,10,11</a>Approximately 4-41% of children and adolescents with juvenile idiopathic arthritis (JIA) have systemic-onset JIA (SoJIA).<a class="elsevierStyleCrossRefs" href="#bib12">12,13</a> This disease subtype is defined as the presence of arthritis in one or more joints associated with a daily fever above 39°C for a minimum period of 15 days and with the presence of at least one of the following manifestations: rheumatoid rash, generalized adenomegaly, pericarditis, pleuritis, hepatomegaly, and/or splenomegaly.<a class="elsevierStyleCrossRef" href="#bib14">14</a>To our knowledge, there are few studies that have evaluated the differences between acute leukemia and SoJIA at disease onset.<a class="elsevierStyleCrossRefs" href="#bib10">10,11</a> Ostrov et al<a class="elsevierStyleCrossRef" href="#bib10">10</a> showed that musculoskeletal pain causing nighttime wakening was more prevalent in eight leukemia and two acute nonlymphocytic leukemia patients vs. 10 patients with a systemic subtype. Jones et al<a class="elsevierStyleCrossRef" href="#bib11">11</a> compared leukemia vs. JIA patients and demonstrated a high sensitivity and specificity of the combination of hematological abnormalities and nighttime pain for a leukemia diagnosis. In their study, however, the three most important JIA subtypes (oligoarthritis, polyarthritis, and systemic) were included, and only 20% of the patients had SoJIA. Furthermore, these two studies did not describe any other relevant alterations at disease onset, for example, hemorrhagic manifestations, macrophage activation syndrome (MAS), pericarditis, myocarditis, or neutropenia. Finally, a multivariate analysis was not performed in either study.Therefore, we aimed to assess the initial clinical and laboratory features that differentiate leukemia from SoJIA. Kaplan-Meier survival curves in leukemia patients with and without limb pain were also evaluated.METHODS AND MATERIALSThe study period took place from August 1996 to October 2010. During this period, 57 consecutive children and adolescents suffering from leukemia with musculoskeletal manifestations but without blasts on peripheral blood smear or glucocorticoid therapy were selected from a population of 190 patients who had complete medical records (the total population of leukemia patients was 285). In addition, 102 consecutive SoJIA patients who did not receive initial glucocorticoid therapy and who had complete medical records were selected from a total population of 136 SoJIA patients. Leukemia and SoJIA patients were retrospectively studied according to their initial clinical and laboratory features. All of the patients were evaluated by a pediatric oncologist and/or a pediatric rheumatologist at our university hospital.The definitive diagnosis of leukemia was established according to the presence of at least 25% blasts on a bone marrow smear, and all of the slides were reviewed by an expert cytologist. Arthritis was diagnosed according to the International League of Associations for Rheumatology (ILAR) criteria.<a class="elsevierStyleCrossRef" href="#bib14">14</a> The Local Ethics Committee of our hospital approved this study.The initial clinical manifestations and laboratory alterations were evaluated for leukemia and SoJIA patients. The presence of the following initial clinical manifestations were systematically analyzed: fever (axillary temperature ≥37.8°C), rheumatoid rash (erythematous, macular, non-pruritic, and evanescent salmon-colored lesions most commonly over the trunk and proximal limbs), generalized lymph node enlargement, hepatomegaly (liver edge >2 cm above the right costal margin), splenomegaly (palpable spleen), pericarditis and myocarditis (confirmed by Doppler echocardiography), pleuritis (confirmed by thorax radiography and/or thorax ultrasound), weight loss (>2 kg in one month) and bleeding (gingival bleeding, petechiae, ecchymosis, and/or epistaxis).<a class="elsevierStyleCrossRef" href="#bib13">13</a>Musculoskeletal manifestations were defined as the presence of arthralgia (joint pain or tenderness without evidence of inflammation), arthritis (swelling within a joint or a limitation in the range of joint movement with joint pain or tenderness),<a class="elsevierStyleCrossRef" href="#bib14">14</a> subjective complaints of limb pain (bone pain, tenderness or other discomfort in one or more limbs without evidence of inflammation), and nighttime pain (musculoskeletal pain causing nocturnal wakening).The following peripheral blood alterations were systematically evaluated: anemia (<10 g/dl), leukopenia (<4,000/mm3), leukocytosis (>12,000/mm3), neutropenia (<1,000/mm3), thrombocytopenia (<150,000/mm3) and thrombocytosis (>400,000/mm3). The erythrocyte sedimentation rate (ESR) was performed according to the Westergreen method, and high levels were defined as >20 mm/1st hour. High lactic dehydrogenase (LDH) and high uric acid levels were evaluated according to the reference ranges based on the patient's age.The leukemia patients were classified into two major immunophenotypes, B- or T-lineage leukemia. During the study period, all leukemia patients were treated according to the same institutional protocol. The long-term results of this protocol were reviewed every five years.Statistical analysisThe results are presented as the median (range) or mean ± standard deviation for continuous variables and as a number (%) for categorical variables. The data were compared using the Mann-Whitney test for continuous variables to evaluate differences between leukemia and SoJIA patients. For categorical variables, the differences were assessed using Fisher's exact test. A logistic regression analysis (Backward Stepwise) was performed to identify the initial clinical and laboratory features that distinguish leukemia from SoJIA patients. The overall survival was analyzed by the Kaplan-Meier method, and survival curves were compared by the log-rank test in leukemia patients with and without limb pain as well as in the overall group of 190 leukemia patients vs. leukemia patients with limb pain (n = 40). For all statistical tests, the level of significance for independent variables was set at 5% (p<0.05).RESULTSDemographic dataThe median ages at disease onset and at diagnosis were significantly higher in leukemia patients compared to SoJIA patients [5.8 (0.5-14.2) vs. 3.8 (0.5-13.3) years, p = 0.0006 and 6.1 (0.8-14.3) vs. 5 (0.9-15) years, p = 0.0272; respectively]. In contrast, the period between disease onset and diagnosis was significantly shorter in the first group [30 days (3-240) vs. 150 days (42-3210), p<0.0001]. No statistical differences were observed for the female gender in both groups (38% vs. 53%, p = 0.0987). The median follow-up period for leukemia patients was eight years (1-13), and the median of follow-up period for SoJIA patients was 6.9 years (1-14).Clinical featuresThe occurrence of clinical manifestations in leukemia patients compared to SoJIA patients is shown in <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>. The frequencies of limb pain, hepatomegaly, weight loss and hemorrhagic manifestations were significantly higher in leukemia patients than in SoJIA patients (70% vs. 1%, p<0.0001; 54% vs. 32%, p = 0.0075; 30% vs. 8%, p = 0.0005 and 9% vs. 0%, p = 0.0053; respectively).<elsevierMultimedia ident="tbl1"></elsevierMultimedia>The frequencies of arthritis, fever, adenomegaly, rheumatoid rash and pericarditis were significantly lower in leukemia patients than in SoJIA patients (25% vs. 100%, p<0.0001; 68% vs. 100%, p<0.0001; 21% vs. 46%, p = 0.002 and 0% vs. 69%, p<0.0001; 0% vs. 16%, p = 0.0006; respectively). No differences were observed in the frequencies of arthralgia, nighttime pain, splenomegaly, or myocarditis in either group (<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>).Laboratory alterationsThe median hemoglobin, white blood cell count, neutrophil count, and platelet counts were significantly lower in leukemia patients than in SoJIA patients (7 g/dl vs. 9.7 g/dl, p<0.0001; 4.6×103/mm3 vs. 12.3×103/mm3, p<0.0001; 0.8×103/mm3 vs. 7.3×103/mm3, p<0.0001 and 56.5×103/mm3 vs. 490×103/mm3, p<0.0001). Conversely, the median LDH level was significantly higher in leukemia patients than in SoJIA patients (822.5 mg/dl vs. 305 mg/dl, p<0.0001). No differences were observed in the median uric acid levels for the two groups (<a class="elsevierStyleCrossRef" href="#tbl2">Table 2</a>).<elsevierMultimedia ident="tbl2"></elsevierMultimedia>The percentages of anemia, leukopenia, neutropenia, thrombocytopenia, and high LDH levels were statistically higher in leukemia patients than in SoJIA patients (88% vs. 57%, p<0.0001; 39% vs. 1%, p<0.0001; 60% vs. 1%, p<0.0001; 77% vs. 1%, p<0.0001 and 56% vs. 14%, p<0.0001; respectively). In contrast, the frequencies of leukocytosis and thrombocytosis were significantly lower in leukemia patients than in SoJIA patients (17% vs. 54%, p<0.0001 and 2% vs. 68%, p<0.0001; respectively), whereas the levels of uric acid were similarly high in both groups (<a class="elsevierStyleCrossRef" href="#tbl3">Table 3</a>).<elsevierMultimedia ident="tbl3"></elsevierMultimedia>Leukemia patientsThe distributions of immunophenotypes (B- and T-lineages) were similar in leukemia patients with limb pain compared to those without limb pain (98% vs. 88%, p = 0.2 and 2% vs. 12%, p = 0.2; respectively). These immunophenotypes were also similar in the overall group of patients (n = 190) compared to leukemia patients with limb pain (92% vs. 98%, p = 0.3189 and 8% vs. 2%, p = 0.3189; respectively).The percentage of high-risk patients was similar in leukemia patients with limb pain compared to those without limb pain (28% vs. 29%, p = 1.0). In addition, the percentage of high-risk patients was also similar in the overall group of patients compared to leukemia patients with limb pain (41% vs. 28%, p = 0.1527).Multivariate analysisLogistic regression analysis was performed by including the following 10 independent variables that presented a level of statistical significance of ≤20% in the univariate analyses: limb pain, hepatomegaly, splenomegaly, weight loss, hemorrhagic manifestations, anemia, leukopenia, neutropenia, thrombocytopenia and high LDH levels. The choice of the variables included in this model was performed according to the clinical plausibility for a leukemia diagnosis. Only limb pain (OR = 553; 95% CI = 46.48-6580.42; p<0.0001) and thrombocytopenia (OR = 754.13; 95% CI = 64.57-8806.72; p<0.0001) remained independent risk factors that distinguished leukemia from SoJIA patients. The R2 of the Nagelkerke test was 0.91 (<a class="elsevierStyleCrossRef" href="#tbl4">Table 4</a>).<elsevierMultimedia ident="tbl4"></elsevierMultimedia>Kaplan-Meier survival curvesThe Kaplan-Meier overall survival curves were similar in leukemia patients with and without limb pain (p = 0.8322; <a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>). The survival percentage of leukemia patients with limb pain six years after disease onset was 77%. The survival percentage of leukemia patients without limb pain five years after disease onset was 76%.<elsevierMultimedia ident="fig1"></elsevierMultimedia>The overall Kaplan-Meier survival curves were also similar in the overall group of 190 leukemia patients and leukemia patients with limb pain (p = 0.4875; <a class="elsevierStyleCrossRef" href="#fig2">Figure 2</a>). The survival percentage of the overall group of leukemia patients six years after disease onset was 83%, and the survival percentage of leukemia patients with limb pain six years after the disease onset was 77%.<elsevierMultimedia ident="fig2"></elsevierMultimedia>DISCUSSIONTo our knowledge, this is the first study to evaluate the largest series of children and adolescents with leukemia and remarkable musculoskeletal manifestations and compare these patients to those with SoJIA followed in a tertiary pediatric university hospital. The results clearly showed that limb pain and thrombocytopenia discriminate leukemia from SoJIA patients at disease onset.One of the most significant advantages of the present study was a systematic evaluation by the same team of pediatric rheumatologists and oncologists, with the exclusion of patients treated with glucocorticosteroids. In fact, this treatment may delay a malignancy diagnosis and reduce the subsequent response to chemotherapy.<a class="elsevierStyleCrossRef" href="#bib15">15</a> Moreover, not all leukemia patients had blasts in their peripheral blood when they were assessed.Conversely, our study was retrospective in nature and included evaluations of peripheral blood smear abnormalities, acute phase reaction, LDH and uric acid levels. In particular, the last two examinations were not collected in all patients; however, missing values have also been an issue in others studies.<a class="elsevierStyleCrossRefs" href="#bib9">9,11</a>Leukemia is the most common pediatric cancer in the United States<a class="elsevierStyleCrossRef" href="#bib1">1</a> and Brazil.<a class="elsevierStyleCrossRef" href="#bib16">16</a> The disease can present with musculoskeletal findings mimicking rheumatic diseases, including JIA,<a class="elsevierStyleCrossRefs" href="#bib17">17–23</a> rheumatic fever,<a class="elsevierStyleCrossRef" href="#bib5">5</a> juvenile systemic lupus erythematosus, and pediatric vasculitis,<a class="elsevierStyleCrossRefs" href="#bib6">6,9</a> as reported by our pediatric rheumatology and oncology services.<a class="elsevierStyleCrossRef" href="#bib7">7</a> The initial presentation of pediatric leukemia consists of various osteoarticular signals and symptoms, including arthralgia, arthritis and limb pain, which may cause nighttime wakening.<a class="elsevierStyleCrossRefs" href="#bib6">6–11</a>,In addition, JIA includes seven different subtypes, arthritis persisting for more than six weeks and a disease onset before the age of 16.<a class="elsevierStyleCrossRef" href="#bib14">14</a> SoJIA is a particular and infrequent subtype of JIA and is very similar to adult-onset Still's disease<a class="elsevierStyleCrossRef" href="#bib24">24</a> with a specific clinical diagnosis and cytokine profile, as previously described by our group.<a class="elsevierStyleCrossRefs" href="#bib25">25,26</a> Children and adolescents with SoJIA have prominent extra-articular manifestations and a significant elevation in acute phase reactants.<a class="elsevierStyleCrossRef" href="#bib13">13</a>The differential diagnosis of suspected SoJIA may be very difficult, particularly at disease onset, when the patient may have only systemic manifestations without arthritis. Therefore, the possibility of leukemia should be always considered, as patients with SoJIA could have a longer period between disease onset and diagnosis, as observed here. Moreover, these two diseases have an impact on morbidity and health-related quality of life.<a class="elsevierStyleCrossRef" href="#bib27">27</a>In the univariate analysis, limb pain, hepatomegaly, weight loss, and hemorrhagic manifestations were predominantly observed in our leukemia patients compared to SoJIA patients, consistent with previous observations.<a class="elsevierStyleCrossRefs" href="#bib7">7–9</a> We also found higher levels of anemia, leukopenia, neutropenia, thrombocytopenia, and LDH in our acute lymphoblastic leukemia patients, similar to the findings in other studies.<a class="elsevierStyleCrossRefs" href="#bib5">5–7</a>, , Interestingly, Wallendal et al<a class="elsevierStyleCrossRef" href="#bib20">20</a> showed that serum LDH levels were significantly higher in cancer patients, including eight patients with leukemia.Remarkably, we found that limb pain and thrombocytopenia differentiated leukemia from SoJIA patients. The logistic regression revealed a wide confidence interval; however, the minimum values of these confidence intervals for both of the independent variables were high enough to be considered. Importantly, the elevated R2 value of the Nagelkerke test showed that the mathematical model of this multivariate analysis was well adjusted to explain this occurrence, indicating that these two independent variables were associated with leukemia in 91% of our patients.Of note, Jones et al<a class="elsevierStyleCrossRef" href="#bib11">11</a> showed that the three most important predictive factors for a pediatric leukemia diagnosis were leukopenia, thrombocytopenia, and a history of nighttime pain. In this multicenter study, the authors included the three most frequent JIA subtypes (pauciarticular, polyarticular, and systemic).In the present study, arthritis and other extra-articular manifestations such as fever, adenomegaly, rheumatoid rash, and pericarditis were predominantly observed in SoJIA patients. Likewise, leukocytosis and thrombocytosis were frequently seen in the patients with this pediatric rheumatic disease and could distinguish them from leukemia patients. The presence of bicytopenia or pancytopenia should also exclude MAS, which is a potential life-threatening complication of SoJIA<a class="elsevierStyleCrossRefs" href="#bib13">13,24,26,28</a> and can rarely be one of the first manifestations of this disease. None of SoJIA patients had MAS at disease onset, and none died during the evaluation.In conclusion, the present study emphasizes the importance of investigating leukemia in children and adolescents that present with musculoskeletal manifestations, and in particular, those with limb pain and thrombocytopenia. These symptoms may mimic SoJIA, even in the absence of blasts on the peripheral blood smear." "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "xpalclavsec1582212" "titulo" => "KEYWORDS" ] 1 => array:2 [ "identificador" => "cesec10" "titulo" => "INTRODUCTION" ] 2 => array:3 [ "identificador" => "cesec20" "titulo" => "METHODS AND MATERIALS" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "cesec30" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "cesec40" "titulo" => "Statistical analysis" ] ] ] ] ] 3 => array:3 [ "identificador" => "cesec50" "titulo" => "RESULTS" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "cesec60" "titulo" => "Demographic data" ] 1 => array:2 [ "identificador" => "cesec70" "titulo" => "Clinical features" ] 2 => array:2 [ "identificador" => "cesec80" "titulo" => "Laboratory alterations" ] 3 => array:2 [ "identificador" => "cesec90" "titulo" => "Leukemia patients" ] 4 => array:2 [ "identificador" => "cesec100" "titulo" => "Multivariate analysis" ] 5 => array:2 [ "identificador" => "cesec110" "titulo" => "Kaplan-Meier survival curves" ] ] ] 4 => array:2 [ "identificador" => "cesec120" "titulo" => "DISCUSSION" ] 5 => array:2 [ "identificador" => "xack639229" "titulo" => "ACKNOWLEDGMENTS" ] 6 => array:1 [ "titulo" => "REFERENCES" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-02-17" "fechaAceptado" => "2011-03-21" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "KEYWORDS" "identificador" => "xpalclavsec1582212" "palabras" => array:5 [ 0 => "Acute lymphoblastic leukemia" 1 => "Juvenile idiopathic arthritis" 2 => "Children" 3 => "Limb pain" 4 => "Thrombocytopenia" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "resumen" => "OBJECTIVE:To assess clinical and laboratory features that differentiate acute lymphoblastic leukemia from systemic juvenile idiopathic arthritis at disease onset. METHODS:Fifty-seven leukemia patients with musculoskeletal involvement, without blasts on peripheral blood and without glucocorticoid therapy at disease onset and 102 systemic juvenile idiopathic arthritis patients (International League of Associations for Rheumatology criteria) were retrospectively evaluated. The following features were examined: fever, rheumatoid rash, arthritis, limb pain, hepatomegaly, splenomegaly, pericarditis, myocarditis, pleuritis, weight loss, bleeding, anemia, leukopenia, neutropenia, thrombocytopenia, erythrocyte sedimentation rate, and lactic dehydrogenase levels. RESULTS:The median age at disease onset was significantly higher in leukemia patients than in those with systemic-onset juvenile idiopathic arthritis (5.8 vs. 3.8 years). In addition, the frequencies of limb pain, hepatomegaly, weight loss and hemorrhagic manifestations were significantly higher in leukemia patients than in systemic-onset juvenile idiopathic arthritis patients (70% vs. 1%, 54% vs. 32%, 30% vs. 8%, and 9% vs. 0%, respectively). Likewise, the frequencies of anemia, leukopenia, neutropenia, thrombocytopenia and high lactic dehydrogenase levels were statistically higher in leukemia patients than in patients with systemic-onset juvenile idiopathic arthritis (88% vs. 57%, 39% vs. 1%, 60% vs. 1%, 77% vs. 1%, and 56% vs. 14%, respectively). Remarkably, multivariate analysis revealed that limb pain (OR = 553; 95% CI = 46.48-6580.42) and thrombocytopenia (OR = 754.13; 95% CI = 64.57-8806.72) were significant independent variables that differentiated leukemia from systemic-onset juvenile idiopathic arthritis. The R2 of the Nagelkerke test was 0.91, and the Kaplan-Meier survival curves were similar for acute lymphoblastic leukemia patients with and without limb pain. CONCLUSION:Our study emphasizes the importance of investigating leukemia in patients presenting with musculoskeletal manifestations and, in particular, limb pain associated with thrombocytopenia." "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" => "No potential conflict of interest was reported." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 334 "Ancho" => 450 "Tamanyo" => 22073 ] ] "descripcion" => array:1 [ "en" => "The Kaplan-Meier overall survival curves between leukemia patients without (n = 17) and with limb pain (n = 40) (p = 0.8322)." ] ] 1 => array:7 [ "identificador" => "fig2" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 349 "Ancho" => 442 "Tamanyo" => 23359 ] ] "descripcion" => array:1 [ "en" => "The Kaplan-Meier overall survival curves between the whole group of leukemia patients (n = 190) and leukemia patients with limb pain (n = 40) (p = 0.4875)." ] ] 2 => array:7 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Values expressed in n (%)." "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">Variables \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">LEUKEMIA (n = 57) \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">SoJIA (n = 102) \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">p-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">Arthralgia \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">40 (70) \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">75 (73) \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">0.7128 \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">Arthritis \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 (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="center" valign="top">102 (100) \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">Limb 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="center" valign="top">40 (70) \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="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">Nighttime 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="center" valign="top">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">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">0.6183 \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">Fever \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">39 (68) \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">102 (100) \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">Hepatomegaly \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">31 (54) \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 (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">0.0075 \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">Splenomegaly \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 (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">31 (30) \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">0.0602 \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">Adenomegaly \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 (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="center" valign="top">47 (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">0.002 \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="center" valign="top">17 (30) \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 (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="char" valign="top">0.0005 \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">Hemorrhagic manifestations \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 (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 (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">0.0053 \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">Rheumatoid rash \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">70 (69) \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">Pericarditis \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">16 (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">0.0006 \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">Myocarditis \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 (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" style="border-bottom: 2px solid black">8 (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="char" valign="top" style="border-bottom: 2px solid black">0.0513 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Initial clinical manifestations in acute lymphoblastic leukemia patients vs. systemic-onset juvenile idiopathic arthritis patients." ] ] 3 => array:7 [ "identificador" => "tbl2" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Values expressed in median (range), WBC - white blood cell count, LDH - lactic dehydrogenase." "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">Variables \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">LEUKEMIA (n = 57) \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">SoJIA (n = 102) \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">p-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">Hemoglobin (g/dl) \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">7 (3.1–11.3) \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">9.7 (5.4–15.5) \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"><0.0001 \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">WBC (x103/mm3) \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 (0.5–80) \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">12.3 (3.1–71.8) \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"><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">Neutrophils count (x103/mm3) \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">0.8 (0–15.6) \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">7.3 (0.7–69.7) \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"><0.0001 \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">Platelets count (x103/mm3) \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">56.5 (12.8–499) \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">490 (70–1200) \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"><0.0001 \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">LDH (mg/dl) \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">822.5 (167–7900) \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">305 (13–4486) \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"><0.0001 \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" style="border-bottom: 2px solid black">Uric acid (mg/dl) \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">4.1 (1.3–14.4) \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" style="border-bottom: 2px solid black">3.7 (0–6.1) \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">0.2209 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Initial laboratory alterations in acute lymphoblastic leukemia patients vs. systemic-onset juvenile idiopathic arthritis patients." ] ] 4 => array:7 [ "identificador" => "tbl3" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "LDH - lactic dehydrogenase," "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">Variables \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">LEUKEMIA (n = 57) N/n (%) \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">SoJIA (n = 102) N/n (%) \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">p-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">Anemia \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">50/57 \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">58/102 \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">(<10 g/dl) \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">(88) \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">(57) \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">Leukopenia \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">22/57 \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">1/102 \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">(<4.000/mm3) \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">(39) \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) \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">Leukocytosis \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">10/57 \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">55/102 \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">(>12.000/mm3) \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) \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">(54) \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">Neutropenia \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">34/57 \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">1/102 \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">(<1.000/mm3) \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">(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">(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="" 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">Thrombocytopenia \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">44/57 \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">1/102 \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">(<150.000/mm3) \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">(77) \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) \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">Thrombocytosis \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">1/57 \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">69/102 \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">(>400.000/mm3) \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) \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">(68) \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">High LDH \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">32/57 \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">6/43 \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="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">(mg/dl) <a class="elsevierStyleCrossRef" href="#tfn4">*</a> \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">(56) \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) \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">High Uric acid \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">19/57 \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">3/11 \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">0.73 \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" style="border-bottom: 2px solid black">(mg/dl) <a class="elsevierStyleCrossRef" href="#tfn4">*</a> \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">(33) \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">(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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tfn4" "etiqueta" => "*" "nota" => "reference range based on age." ] ] ] "descripcion" => array:1 [ "en" => "Initial laboratory alterations in acute lymphoblastic leukemia patients vs. systemic-onset juvenile idiopathic arthritis patients." ] ] 5 => array:7 [ "identificador" => "tbl4" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "OR - odds ratio, CI – confidence interval, R2 - R2 of Nagelkerke test." "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">Independent variable \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">OR \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">95% CI \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">R2 \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">p-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">Limb 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="center" valign="top">553 \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">46.48-6580.42 \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">0.91 \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"><0.0001 \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" style="border-bottom: 2px solid black">Thrombocytopenia \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">754.13 \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="center" valign="top" style="border-bottom: 2px solid black">64.57-8806.72 \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" style="border-bottom: 2px solid black"> \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"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Logistic regression analysis to evaluate risk factors distinguishing acute lymphoblastic leukemia from systemic-onset juvenile idiopathic arthritis patients." ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trends in childhood cancer incidence in the U.S. (1992–2004)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ AM Linabery \n \t\t\t\t\t\t\t\t """ 1 => """ JA Ross \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1002/cncr.23169" "Revista" => array:6 [ "tituloSerie" => "Cancer" "fecha" => "2008" "volumen" => "112" "paginaInicial" => "416" "paginaFinal" => "432" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18074355" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1002/cncr.23169" "WWW" => array:1 [ "link" => "10.1002/cncr.23169" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trends in childhood cancer mortality–United States, 1990–2004" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "CDC" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "MMWR Morb Mortal Wkly Rep" "fecha" => "2007" "volumen" => "56" "paginaInicial" => "1257" "paginaFinal" => "1261" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18059256" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028220307111" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Differential diagnosis of neoplastic and rheumatic diseases in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ E Musiej-Nowakowska \n \t\t\t\t\t\t\t\t """ 1 => """ K Rostropowicz-Denisiewicz \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Scand J Rheumatology" "fecha" => "1986" "volumen" => "15" "paginaInicial" => "124" "paginaFinal" => "128" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "10.3109/03009748609102077" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Malignancies in children who initially present with rheumatic complaints" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ DV Cabral \n \t\t\t\t\t\t\t\t """ 1 => """ LB Tucker \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1016/s0022-3476(99)70372-0" "Revista" => array:6 [ "tituloSerie" => "J Pediatr" "fecha" => "1999" "volumen" => "134" "paginaInicial" => "53" "paginaFinal" => "57" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9880449" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1016/s0022-3476(99)70372-0" "WWW" => array:1 [ "link" => "10.1016/S0022-3476(99)70372-0" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rheumatological manifestations of haematological diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ S Menon \n \t\t\t\t\t\t\t\t """ 1 => """ DA Isenberg \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1136/ard.54.10.787" "Revista" => array:6 [ "tituloSerie" => "Ann Rheum Dis" "fecha" => "1995" "volumen" => "54" "paginaInicial" => "787" "paginaFinal" => "795" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7492215" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1136/ard.54.10.787" "WWW" => array:1 [ "link" => "10.1136/ard.54.10.787" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Musculoskeletal manifestations as the onset of acute leukemias in childhood" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => """ CM Barbosa \n \t\t\t\t\t\t\t\t """ 1 => """ C Nakamura \n \t\t\t\t\t\t\t\t """ 2 => """ MT Terreri \n \t\t\t\t\t\t\t\t """ 3 => """ ML Lee \n \t\t\t\t\t\t\t\t """ 4 => """ AS Petrilli \n \t\t\t\t\t\t\t\t """ 5 => """ Hilario \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "J Pediatr (Rio J)" "fecha" => "2002" "volumen" => "78" "paginaInicial" => "481" "paginaFinal" => "484" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14647728" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028215004641" "estado" => "S300" "issn" => "00150282" ] ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "10.1590/S0021-75572002000600007" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Musculoskeletal involvement as a first manifestation of neoplasm disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ LM Campos \n \t\t\t\t\t\t\t\t """ 1 => """ S Goldstein \n \t\t\t\t\t\t\t\t """ 2 => """ RA Santiago \n \t\t\t\t\t\t\t\t """ 3 => """ AA Jesus \n \t\t\t\t\t\t\t\t """ 4 => """ LM Cristofani \n \t\t\t\t\t\t\t\t """ 5 => """ V Odone Filho \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1590/s0104-42302008000200015" "Revista" => array:6 [ "tituloSerie" => "Rev Assoc Med Bras" "fecha" => "2008" "volumen" => "54" "paginaInicial" => "132" "paginaFinal" => "138" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18506321" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1590/s0104-42302008000200015" "WWW" => array:1 [ "link" => "10.1590/S0104-42302008000200015" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bone pain as an initial symptom of childhood acute lymphoblastic leukemia: Association with nearly normal hematologic indexes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ OG Jonsson \n \t\t\t\t\t\t\t\t """ 1 => """ P Sartain \n \t\t\t\t\t\t\t\t """ 2 => """ JM Ducore \n \t\t\t\t\t\t\t\t """ 3 => """ GR Buchanan \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1016/s0022-3476(05)80535-9" "Revista" => array:7 [ "tituloSerie" => "J Pediatr" "fecha" => "1990" "volumen" => "117" "paginaInicial" => "233" "paginaFinal" => "237" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2380822" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028220326844" "estado" => "S300" "issn" => "00150282" ] ] ] 1 => array:2 [ "doi" => "10.1016/s0022-3476(05)80535-9" "WWW" => array:1 [ "link" => "10.1016/S0022-3476(05)80535-9" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteoarticular manifestations as initial presentation of acute leukemias in children and adolescents in Bahia, Brazil" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => """ TC Robazzi \n \t\t\t\t\t\t\t\t """ 1 => """ JH Barreto \n \t\t\t\t\t\t\t\t """ 2 => """ LR Silva \n \t\t\t\t\t\t\t\t """ 3 => """ MB Santiago \n \t\t\t\t\t\t\t\t """ 4 => """ N Mendonça \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1097/MPH.0b013e3181468c55" "Revista" => array:7 [ "tituloSerie" => "J Pediatr Hematol Oncol" "fecha" => "2007" "volumen" => "29" "paginaInicial" => "622" "paginaFinal" => "626" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17805037" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028218304266" "estado" => "S300" "issn" => "00150282" ] ] ] 1 => array:2 [ "doi" => "10.1097/MPH.0b013e3181468c55" "WWW" => array:1 [ "link" => "10.1097/MPH.0b013e3181468c55" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Differentiation of systemic juvenile rheumatoid arthritis from acute leukemia near the onset of disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ BE Ostrov \n \t\t\t\t\t\t\t\t """ 1 => """ DP Goldsmith \n \t\t\t\t\t\t\t\t """ 2 => """ BH Athreya \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1016/s0022-3476(05)83543-7" "Revista" => array:6 [ "tituloSerie" => "J Pediatr" "fecha" => "1993" "volumen" => "122" "paginaInicial" => "595" "paginaFinal" => "598" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8463908" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1016/s0022-3476(05)83543-7" "WWW" => array:1 [ "link" => "10.1016/S0022-3476(05)83543-7" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A multicenter case-control study on predictive factors distinguishing childhood leukemia from juvenile rheumatoid arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => """ OY Jones \n \t\t\t\t\t\t\t\t """ 1 => """ CH Spencer \n \t\t\t\t\t\t\t\t """ 2 => """ SL Bowyer \n \t\t\t\t\t\t\t\t """ 3 => """ PB Dent \n \t\t\t\t\t\t\t\t """ 4 => """ BS Gottlieb \n \t\t\t\t\t\t\t\t """ 5 => """ CE Rabinovich \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "2006" "volumen" => "117" "paginaInicial" => "840" "paginaFinal" => "844" "itemHostRev" => array:3 [ "pii" => "S0015028220327163" "estado" => "S300" "issn" => "00150282" ] ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "10.1542/peds.2005-1515" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Juvenile idiopathic arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ A Ravelli \n \t\t\t\t\t\t\t\t """ 1 => """ A Martini \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(07)60363-8" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2007" "volumen" => "369" "paginaInicial" => "767" "paginaFinal" => "778" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17336654" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1016/S0140-6736(07)60363-8" "WWW" => array:1 [ "link" => "10.1016/S0140-6736(07)60363-8" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Macrophage activation syndrome associated with systemic juvenile idiopathic arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ CA Silva \n \t\t\t\t\t\t\t\t """ 1 => """ CH Silva \n \t\t\t\t\t\t\t\t """ 2 => """ TC Robazzi \n \t\t\t\t\t\t\t\t """ 3 => """ AP Lotito \n \t\t\t\t\t\t\t\t """ 4 => """ A Mendroni Junior \n \t\t\t\t\t\t\t\t """ 5 => """ CM Jacob \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Pediatr (Rio J)" "fecha" => "2004" "volumen" => "80" "paginaInicial" => "517" "paginaFinal" => "522" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15622430" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ RE Petty \n \t\t\t\t\t\t\t\t """ 1 => """ TR Southwood \n \t\t\t\t\t\t\t\t """ 2 => """ P Manners \n \t\t\t\t\t\t\t\t """ 3 => """ J Baum \n \t\t\t\t\t\t\t\t """ 4 => """ DN Glass \n \t\t\t\t\t\t\t\t """ 5 => """ J Goldenberg \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "J Rheumatol" "fecha" => "2004" "volumen" => "31" "paginaInicial" => "390" "paginaFinal" => "392" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14760812" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673619306907" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The adverse effect of prolonged prednisolone pretreatment in children with acute lymphoblastic leukemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ T Révész \n \t\t\t\t\t\t\t\t """ 1 => """ G Kardos \n \t\t\t\t\t\t\t\t """ 2 => """ P Kajtár \n \t\t\t\t\t\t\t\t """ 3 => """ D Schuler \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1002/1097-0142(19850415)55:8<1637::aid-cncr2820550804>3.0.co;2-h" "Revista" => array:7 [ "tituloSerie" => "Cancer" "fecha" => "1985" "volumen" => "55" "paginaInicial" => "1637" "paginaFinal" => "1640" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3856464" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028218304266" "estado" => "S300" "issn" => "00150282" ] ] ] 1 => array:2 [ "doi" => "10.1002/1097-0142(19850415)55:8<1637::aid-cncr2820550804>3.0.co;2-h" "WWW" => array:1 [ "link" => "10.1002/1097-0142(19850415)55:8<1637::AID-CNCR2820550804>3.0.CO;2-H" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cancer incidence among children and adolescents in Brazil: first report of 14 population-based cancer registries" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ B de Camargo \n \t\t\t\t\t\t\t\t """ 1 => """ M de Oliveira Santos \n \t\t\t\t\t\t\t\t """ 2 => """ MS Rebelo \n \t\t\t\t\t\t\t\t """ 3 => """ R de Souza Reis \n \t\t\t\t\t\t\t\t """ 4 => """ S Ferman \n \t\t\t\t\t\t\t\t """ 5 => """ CP Noronha \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1002/ijc.24799" "Revista" => array:6 [ "tituloSerie" => "Int J Cancer" "fecha" => "2010" "volumen" => "126" "paginaInicial" => "715" "paginaFinal" => "720" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19642142" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1002/ijc.24799" "WWW" => array:1 [ "link" => "10.1002/ijc.24799" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Arthritis as a presenting manifestation of malignancy in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => """ J Schaller \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1016/s0022-3476(72)80108-2" "Revista" => array:6 [ "tituloSerie" => "J Pediatr" "fecha" => "1972" "volumen" => "81" "paginaInicial" => "793" "paginaFinal" => "797" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4561480" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1016/s0022-3476(72)80108-2" "WWW" => array:1 [ "link" => "10.1016/S0022-3476(72)80108-2" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute leukemia presenting as arthritis in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ FT Saulsbury \n \t\t\t\t\t\t\t\t """ 1 => """ H Sabio \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Pediatr" "fecha" => "1985" "volumen" => "24" "paginaInicial" => "625" "paginaFinal" => "628" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "10.1177/000992288502401103" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis of malignancies in children with musculoskeletal complaints" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => """ M Gonçalves \n \t\t\t\t\t\t\t\t """ 1 => 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"Revista" => array:7 [ "tituloSerie" => "Isr Med Assoc J" "fecha" => "2009" "volumen" => "11" "paginaInicial" => "635" "paginaFinal" => "636" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20077954" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028221021555" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib27" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Quality of life evaluation in children and adolescents with chronic and/or incapacitating diseases: a Brazilian study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => """ E Kuczynski \n \t\t\t\t\t\t\t\t """ 1 => """ CA Silva \n \t\t\t\t\t\t\t\t """ 2 => """ LM Cristófani \n \t\t\t\t\t\t\t\t """ 3 => """ MH Kiss \n \t\t\t\t\t\t\t\t """ 4 => """ V Odone Filho \n \t\t\t\t\t\t\t\t """ 5 => """ FB Assumpção Jr \n \t\t\t\t\t\t\t\t """ ] ] ] ] 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We thank Prof. Ulysses Dória-Filho for statistical support." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/18075932/0000006600000010/v1_202212011334/S1807593222023201/v1_202212011334/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/18075932/0000006600000010/v1_202212011334/S1807593222023201/v1_202212011334/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222023201?idApp=UINPBA00004N"]

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CLINICAL SCIENCE

Mirian S TamashiroI, Nádia Emi AikawaI,III, Lucia Maria A CamposI, Lílian Maria CristofaniII, Vicente Odone-FilhoII, Clovis A SilvaI,III,

Corresponding author

clovis.silva@icr.usp.br

Tel.: 00 55 11 26618563

I Pediatric Rheumatology Unit of Instituto da Criança of Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.

II Pediatric Oncology Unit of Instituto da Criança of Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.

III Division of Rheumatology of Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.

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          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">The Kaplan-Meier overall survival curves between the whole group of leukemia patients &#40;n &#61; 190&#41; and leukemia patients with limb pain &#40;n &#61; 40&#41; &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#46;4875&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Acute lymphoblastic leukemia is the most prevalent cancer in children and adolescents<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;2</a> and is the most frequent malignant neoplasm associated with musculoskeletal complaints at disease onset&#46;<a class="elsevierStyleCrossRefs" href="#bib3">3&#8211;9</a> The main clinical osteoarticular manifestations in early leukemia include limb pain&#44; nighttime pain&#44; arthralgia&#44; and arthritis&#46;<a class="elsevierStyleCrossRefs" href="#bib4">4&#8211;9</a> Moreover&#44; pediatric leukemia may develop clinical features and laboratory alterations that mimic rheumatic diseases&#44; in particular systemic-onset juvenile idiopathic arthritis &#40;also known as juvenile rheumatoid arthritis&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib7">7&#44;10&#44;11</a></p><p id="para20" class="elsevierStylePara elsevierViewall">Approximately 4-41&#37; of children and adolescents with juvenile idiopathic arthritis &#40;JIA&#41; have systemic-onset JIA &#40;SoJIA&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib12">12&#44;13</a> This disease subtype is defined as the presence of arthritis in one or more joints associated with a daily fever above 39&#176;C for a minimum period of 15 days and with the presence of at least one of the following manifestations&#58; rheumatoid rash&#44; generalized adenomegaly&#44; pericarditis&#44; pleuritis&#44; hepatomegaly&#44; and&#47;or splenomegaly&#46;<a class="elsevierStyleCrossRef" href="#bib14">14</a></p><p id="para30" class="elsevierStylePara elsevierViewall">To our knowledge&#44; there are few studies that have evaluated the differences between acute leukemia and SoJIA at disease onset&#46;<a class="elsevierStyleCrossRefs" href="#bib10">10&#44;11</a> Ostrov et al<a class="elsevierStyleCrossRef" href="#bib10">10</a> showed that musculoskeletal pain causing nighttime wakening was more prevalent in eight leukemia and two acute nonlymphocytic leukemia patients vs&#46; 10 patients with a systemic subtype&#46; Jones et al<a class="elsevierStyleCrossRef" href="#bib11">11</a> compared leukemia vs&#46; JIA patients and demonstrated a high sensitivity and specificity of the combination of hematological abnormalities and nighttime pain for a leukemia diagnosis&#46; In their study&#44; however&#44; the three most important JIA subtypes &#40;oligoarthritis&#44; polyarthritis&#44; and systemic&#41; were included&#44; and only 20&#37; of the patients had SoJIA&#46; Furthermore&#44; these two studies did not describe any other relevant alterations at disease onset&#44; for example&#44; hemorrhagic manifestations&#44; macrophage activation syndrome &#40;MAS&#41;&#44; pericarditis&#44; myocarditis&#44; or neutropenia&#46; Finally&#44; a multivariate analysis was not performed in either study&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">Therefore&#44; we aimed to assess the initial clinical and laboratory features that differentiate leukemia from SoJIA&#46; Kaplan-Meier survival curves in leukemia patients with and without limb pain were also evaluated&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">METHODS AND MATERIALS</span><p id="para50" class="elsevierStylePara elsevierViewall">The study period took place from August 1996 to October 2010&#46; During this period&#44; 57 consecutive children and adolescents suffering from leukemia with musculoskeletal manifestations but without blasts on peripheral blood smear or glucocorticoid therapy were selected from a population of 190 patients who had complete medical records &#40;the total population of leukemia patients was 285&#41;&#46; In addition&#44; 102 consecutive SoJIA patients who did not receive initial glucocorticoid therapy and who had complete medical records were selected from a total population of 136 SoJIA patients&#46; Leukemia and SoJIA patients were retrospectively studied according to their initial clinical and laboratory features&#46; All of the patients were evaluated by a pediatric oncologist and&#47;or a pediatric rheumatologist at our university hospital&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">The definitive diagnosis of leukemia was established according to the presence of at least 25&#37; blasts on a bone marrow smear&#44; and all of the slides were reviewed by an expert cytologist&#46; Arthritis was diagnosed according to the International League of Associations for Rheumatology &#40;ILAR&#41; criteria&#46;<a class="elsevierStyleCrossRef" href="#bib14">14</a> The Local Ethics Committee of our hospital approved this study&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">The initial clinical manifestations and laboratory alterations were evaluated for leukemia and SoJIA patients&#46; The presence of the following initial clinical manifestations were systematically analyzed&#58; fever &#40;axillary temperature &#8805;37&#46;8&#176;C&#41;&#44; rheumatoid rash &#40;erythematous&#44; macular&#44; non-pruritic&#44; and evanescent salmon-colored lesions most commonly over the trunk and proximal limbs&#41;&#44; generalized lymph node enlargement&#44; hepatomegaly &#40;liver edge &#62;2&#160;cm above the right costal margin&#41;&#44; splenomegaly &#40;palpable spleen&#41;&#44; pericarditis and myocarditis &#40;confirmed by Doppler echocardiography&#41;&#44; pleuritis &#40;confirmed by thorax radiography and&#47;or thorax ultrasound&#41;&#44; weight loss &#40;&#62;2&#160;kg in one month&#41; and bleeding &#40;gingival bleeding&#44; petechiae&#44; ecchymosis&#44; and&#47;or epistaxis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib13">13</a></p><p id="para80" class="elsevierStylePara elsevierViewall">Musculoskeletal manifestations were defined as the presence of arthralgia &#40;joint pain or tenderness without evidence of inflammation&#41;&#44; arthritis &#40;swelling within a joint or a limitation in the range of joint movement with joint pain or tenderness&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib14">14</a> subjective complaints of limb pain &#40;bone pain&#44; tenderness or other discomfort in one or more limbs without evidence of inflammation&#41;&#44; and nighttime pain &#40;musculoskeletal pain causing nocturnal wakening&#41;&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">The following peripheral blood alterations were systematically evaluated&#58; anemia &#40;&#60;10&#160;g&#47;dl&#41;&#44; leukopenia &#40;&#60;4&#44;000&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; leukocytosis &#40;&#62;12&#44;000&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; neutropenia &#40;&#60;1&#44;000&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; thrombocytopenia &#40;&#60;150&#44;000&#47;mm<span class="elsevierStyleSup">3</span>&#41; and thrombocytosis &#40;&#62;400&#44;000&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#46; The erythrocyte sedimentation rate &#40;ESR&#41; was performed according to the Westergreen method&#44; and high levels were defined as &#62;20&#160;mm&#47;1<span class="elsevierStyleSup">st</span> hour&#46; High lactic dehydrogenase &#40;LDH&#41; and high uric acid levels were evaluated according to the reference ranges based on the patient&#39;s age&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">The leukemia patients were classified into two major immunophenotypes&#44; B- or T-lineage leukemia&#46; During the study period&#44; all leukemia patients were treated according to the same institutional protocol&#46; The long-term results of this protocol were reviewed every five years&#46;</p><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">Statistical analysis</span><p id="para110" class="elsevierStylePara elsevierViewall">The results are presented as the median &#40;range&#41; or mean &#177; standard deviation for continuous variables and as a number &#40;&#37;&#41; for categorical variables&#46; The data were compared using the Mann-Whitney test for continuous variables to evaluate differences between leukemia and SoJIA patients&#46; For categorical variables&#44; the differences were assessed using Fisher&#39;s exact test&#46; A logistic regression analysis &#40;Backward Stepwise&#41; was performed to identify the initial clinical and laboratory features that distinguish leukemia from SoJIA patients&#46; The overall survival was analyzed by the Kaplan-Meier method&#44; and survival curves were compared by the log-rank test in leukemia patients with and without limb pain as well as in the overall group of 190 leukemia patients vs&#46; leukemia patients with limb pain &#40;n &#61; 40&#41;&#46; For all statistical tests&#44; the level of significance for independent variables was set at 5&#37; &#40;<span class="elsevierStyleItalic">p</span>&#60;0&#46;05&#41;&#46;</p></span></span></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">RESULTS</span><span id="cesec60" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">Demographic data</span><p id="para120" class="elsevierStylePara elsevierViewall">The median ages at disease onset and at diagnosis were significantly higher in leukemia patients compared to SoJIA patients &#91;5&#46;8 &#40;0&#46;5-14&#46;2&#41; vs&#46; 3&#46;8 &#40;0&#46;5-13&#46;3&#41; years&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;0006 and 6&#46;1 &#40;0&#46;8-14&#46;3&#41; vs&#46; 5 &#40;0&#46;9-15&#41; years&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;0272&#59; respectively&#93;&#46; In contrast&#44; the period between disease onset and diagnosis was significantly shorter in the first group &#91;30 days &#40;3-240&#41; vs&#46; 150 days &#40;42-3210&#41;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#93;&#46; No statistical differences were observed for the female gender in both groups &#40;38&#37; vs&#46; 53&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;0987&#41;&#46; The median follow-up period for leukemia patients was eight years &#40;1-13&#41;&#44; and the median of follow-up period for SoJIA patients was 6&#46;9 years &#40;1-14&#41;&#46;</p></span><span id="cesec70" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle110">Clinical features</span><p id="para130" class="elsevierStylePara elsevierViewall">The occurrence of clinical manifestations in leukemia patients compared to SoJIA patients is shown in <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#46; The frequencies of limb pain&#44; hepatomegaly&#44; weight loss and hemorrhagic manifestations were significantly higher in leukemia patients than in SoJIA patients &#40;70&#37; vs&#46; 1&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#59; 54&#37; vs&#46; 32&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;0075&#59; 30&#37; vs&#46; 8&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;0005 and 9&#37; vs&#46; 0&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;0053&#59; respectively&#41;&#46;</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="para140" class="elsevierStylePara elsevierViewall">The frequencies of arthritis&#44; fever&#44; adenomegaly&#44; rheumatoid rash and pericarditis were significantly lower in leukemia patients than in SoJIA patients &#40;25&#37; vs&#46; 100&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#59; 68&#37; vs&#46; 100&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#59; 21&#37; vs&#46; 46&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;002 and 0&#37; vs&#46; 69&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#59; 0&#37; vs&#46; 16&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;0006&#59; respectively&#41;&#46; No differences were observed in the frequencies of arthralgia&#44; nighttime pain&#44; splenomegaly&#44; or myocarditis in either group &#40;<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41;&#46;</p></span><span id="cesec80" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle120">Laboratory alterations</span><p id="para150" class="elsevierStylePara elsevierViewall">The median hemoglobin&#44; white blood cell count&#44; neutrophil count&#44; and platelet counts were significantly lower in leukemia patients than in SoJIA patients &#40;7&#160;g&#47;dl vs&#46; 9&#46;7&#160;g&#47;dl&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#59; 4&#46;6&#215;10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span> vs&#46; 12&#46;3&#215;10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span>&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#59; 0&#46;8&#215;10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span> vs&#46; 7&#46;3&#215;10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span>&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001 and 56&#46;5&#215;10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span> vs&#46; 490&#215;10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span>&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#41;&#46; Conversely&#44; the median LDH level was significantly higher in leukemia patients than in SoJIA patients &#40;822&#46;5&#160;mg&#47;dl vs&#46; 305&#160;mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#41;&#46; No differences were observed in the median uric acid levels for the two groups &#40;<a class="elsevierStyleCrossRef" href="#tbl2">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl2"></elsevierMultimedia><p id="para160" class="elsevierStylePara elsevierViewall">The percentages of anemia&#44; leukopenia&#44; neutropenia&#44; thrombocytopenia&#44; and high LDH levels were statistically higher in leukemia patients than in SoJIA patients &#40;88&#37; vs&#46; 57&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#59; 39&#37; vs&#46; 1&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#59; 60&#37; vs&#46; 1&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#59; 77&#37; vs&#46; 1&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001 and 56&#37; vs&#46; 14&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#59; respectively&#41;&#46; In contrast&#44; the frequencies of leukocytosis and thrombocytosis were significantly lower in leukemia patients than in SoJIA patients &#40;17&#37; vs&#46; 54&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001 and 2&#37; vs&#46; 68&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#59; respectively&#41;&#44; whereas the levels of uric acid were similarly high in both groups &#40;<a class="elsevierStyleCrossRef" href="#tbl3">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl3"></elsevierMultimedia></span><span id="cesec90" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle130">Leukemia patients</span><p id="para170" class="elsevierStylePara elsevierViewall">The distributions of immunophenotypes &#40;B- and T-lineages&#41; were similar in leukemia patients with limb pain compared to those without limb pain &#40;98&#37; vs&#46; 88&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;2 and 2&#37; vs&#46; 12&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;2&#59; respectively&#41;&#46; These immunophenotypes were also similar in the overall group of patients &#40;n &#61; 190&#41; compared to leukemia patients with limb pain &#40;92&#37; vs&#46; 98&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;3189 and 8&#37; vs&#46; 2&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;3189&#59; respectively&#41;&#46;</p><p id="para180" class="elsevierStylePara elsevierViewall">The percentage of high-risk patients was similar in leukemia patients with limb pain compared to those without limb pain &#40;28&#37; vs&#46; 29&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 1&#46;0&#41;&#46; In addition&#44; the percentage of high-risk patients was also similar in the overall group of patients compared to leukemia patients with limb pain &#40;41&#37; vs&#46; 28&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;1527&#41;&#46;</p></span><span id="cesec100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle140">Multivariate analysis</span><p id="para190" class="elsevierStylePara elsevierViewall">Logistic regression analysis was performed by including the following 10 independent variables that presented a level of statistical significance of &#8804;20&#37; in the univariate analyses&#58; limb pain&#44; hepatomegaly&#44; splenomegaly<span class="elsevierStyleBold">&#44;</span> weight loss&#44; hemorrhagic manifestations&#44; anemia&#44; leukopenia&#44; neutropenia&#44; thrombocytopenia and high LDH levels&#46; The choice of the variables included in this model was performed according to the clinical plausibility for a leukemia diagnosis&#46; Only limb pain &#40;OR &#61; 553&#59; 95&#37; CI &#61; 46&#46;48-6580&#46;42&#59; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#41; and thrombocytopenia &#40;OR &#61; 754&#46;13&#59; 95&#37; CI &#61; 64&#46;57-8806&#46;72&#59; <span class="elsevierStyleItalic">p</span>&#60;0&#46;0001&#41; remained independent risk factors that distinguished leukemia from SoJIA patients&#46; The R2 of the Nagelkerke test was 0&#46;91 &#40;<a class="elsevierStyleCrossRef" href="#tbl4">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl4"></elsevierMultimedia></span><span id="cesec110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle150">Kaplan-Meier survival curves</span><p id="para200" class="elsevierStylePara elsevierViewall">The Kaplan-Meier overall survival curves were similar in leukemia patients with and without limb pain &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#46;8322&#59; <a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>&#41;&#46; The survival percentage of leukemia patients with limb pain six years after disease onset was 77&#37;&#46; The survival percentage of leukemia patients without limb pain five years after disease onset was 76&#37;&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p id="para210" class="elsevierStylePara elsevierViewall">The overall Kaplan-Meier survival curves were also similar in the overall group of 190 leukemia patients and leukemia patients with limb pain &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#46;4875&#59; <a class="elsevierStyleCrossRef" href="#fig2">Figure 2</a>&#41;&#46; The survival percentage of the overall group of leukemia patients six years after disease onset was 83&#37;&#44; and the survival percentage of leukemia patients with limb pain six years after the disease onset was 77&#37;&#46;</p><elsevierMultimedia ident="fig2"></elsevierMultimedia></span></span><span id="cesec120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle160">DISCUSSION</span><p id="para220" class="elsevierStylePara elsevierViewall">To our knowledge&#44; this is the first study to evaluate the largest series of children and adolescents with leukemia and remarkable musculoskeletal manifestations and compare these patients to those with SoJIA followed in a tertiary pediatric university hospital&#46; The results clearly showed that limb pain and thrombocytopenia discriminate leukemia from SoJIA patients at disease onset&#46;</p><p id="para230" class="elsevierStylePara elsevierViewall">One of the most significant advantages of the present study was a systematic evaluation by the same team of pediatric rheumatologists and oncologists&#44; with the exclusion of patients treated with glucocorticosteroids&#46; In fact&#44; this treatment may delay a malignancy diagnosis and reduce the subsequent response to chemotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib15">15</a> Moreover&#44; not all leukemia patients had blasts in their peripheral blood when they were assessed&#46;</p><p id="para240" class="elsevierStylePara elsevierViewall">Conversely&#44; our study was retrospective in nature and included evaluations of peripheral blood smear abnormalities&#44; acute phase reaction&#44; LDH and uric acid levels&#46; In particular&#44; the last two examinations were not collected in all patients&#59; however&#44; missing values have also been an issue in others studies&#46;<a class="elsevierStyleCrossRefs" href="#bib9">9&#44;11</a></p><p id="para250" class="elsevierStylePara elsevierViewall">Leukemia is the most common pediatric cancer in the United States<a class="elsevierStyleCrossRef" href="#bib1">1</a> and Brazil&#46;<a class="elsevierStyleCrossRef" href="#bib16">16</a> The disease can present with musculoskeletal findings mimicking rheumatic diseases&#44; including JIA&#44;<a class="elsevierStyleCrossRefs" href="#bib17">17&#8211;23</a> rheumatic fever&#44;<a class="elsevierStyleCrossRef" href="#bib5">5</a> juvenile systemic lupus erythematosus&#44; and pediatric vasculitis&#44;<a class="elsevierStyleCrossRefs" href="#bib6">6&#44;9</a> as reported by our pediatric rheumatology and oncology services&#46;<a class="elsevierStyleCrossRef" href="#bib7">7</a> The initial presentation of pediatric leukemia consists of various osteoarticular signals and symptoms&#44; including arthralgia&#44; arthritis and limb pain&#44; which may cause nighttime wakening&#46;<a class="elsevierStyleCrossRefs" href="#bib6">6&#8211;11</a>&#44;</p><p id="para260" class="elsevierStylePara elsevierViewall">In addition&#44; JIA includes seven different subtypes&#44; arthritis persisting for more than six weeks and a disease onset before the age of 16&#46;<a class="elsevierStyleCrossRef" href="#bib14">14</a> SoJIA is a particular and infrequent subtype of JIA and is very similar to adult-onset Still&#39;s disease<a class="elsevierStyleCrossRef" href="#bib24">24</a> with a specific clinical diagnosis and cytokine profile&#44; as previously described by our group&#46;<a class="elsevierStyleCrossRefs" href="#bib25">25&#44;26</a> Children and adolescents with SoJIA have prominent extra-articular manifestations and a significant elevation in acute phase reactants&#46;<a class="elsevierStyleCrossRef" href="#bib13">13</a></p><p id="para270" class="elsevierStylePara elsevierViewall">The differential diagnosis of suspected SoJIA may be very difficult&#44; particularly at disease onset&#44; when the patient may have only systemic manifestations without arthritis&#46; Therefore&#44; the possibility of leukemia should be always considered&#44; as patients with SoJIA could have a longer period between disease onset and diagnosis&#44; as observed here&#46; Moreover&#44; these two diseases have an impact on morbidity and health-related quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib27">27</a></p><p id="para280" class="elsevierStylePara elsevierViewall">In the univariate analysis&#44; limb pain&#44; hepatomegaly&#44; weight loss&#44; and hemorrhagic manifestations were predominantly observed in our leukemia patients compared to SoJIA patients&#44; consistent with previous observations&#46;<a class="elsevierStyleCrossRefs" href="#bib7">7&#8211;9</a> We also found higher levels of anemia&#44; leukopenia&#44; neutropenia&#44; thrombocytopenia&#44; and LDH in our acute lymphoblastic leukemia patients&#44; similar to the findings in other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib5">5&#8211;7</a>&#44; &#44; Interestingly&#44; Wallendal et al<a class="elsevierStyleCrossRef" href="#bib20">20</a> showed that serum LDH levels were significantly higher in cancer patients&#44; including eight patients with leukemia&#46;</p><p id="para290" class="elsevierStylePara elsevierViewall">Remarkably&#44; we found that limb pain and thrombocytopenia differentiated leukemia from SoJIA patients&#46; The logistic regression revealed a wide confidence interval&#59; however&#44; the minimum values of these confidence intervals for both of the independent variables were high enough to be considered&#46; Importantly&#44; the elevated R2 value of the Nagelkerke test showed that the mathematical model of this multivariate analysis was well adjusted to explain this occurrence&#44; indicating that these two independent variables were associated with leukemia in 91&#37; of our patients&#46;</p><p id="para300" class="elsevierStylePara elsevierViewall">Of note&#44; Jones et al<a class="elsevierStyleCrossRef" href="#bib11">11</a> showed that the three most important predictive factors for a pediatric leukemia diagnosis were leukopenia&#44; thrombocytopenia&#44; and a history of nighttime pain&#46; In this multicenter study&#44; the authors included the three most frequent JIA subtypes &#40;pauciarticular&#44; polyarticular&#44; and systemic&#41;&#46;</p><p id="para310" class="elsevierStylePara elsevierViewall">In the present study&#44; arthritis and other extra-articular manifestations such as fever&#44; adenomegaly&#44; rheumatoid rash&#44; and pericarditis were predominantly observed in SoJIA patients&#46; Likewise&#44; leukocytosis and thrombocytosis were frequently seen in the patients with this pediatric rheumatic disease and could distinguish them from leukemia patients&#46; The presence of bicytopenia or pancytopenia should also exclude MAS&#44; which is a potential life-threatening complication of SoJIA<a class="elsevierStyleCrossRefs" href="#bib13">13&#44;24&#44;26&#44;28</a> and can rarely be one of the first manifestations of this disease&#46; None of SoJIA patients had MAS at disease onset&#44; and none died during the evaluation&#46;</p><p id="para320" class="elsevierStylePara elsevierViewall">In conclusion&#44; the present study emphasizes the importance of investigating leukemia in children and adolescents that present with musculoskeletal manifestations&#44; and in particular&#44; those with limb pain and thrombocytopenia&#46; These symptoms may mimic SoJIA&#44; even in the absence of blasts on the peripheral blood smear&#46;</p></span></span>"
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            3 => array:2 [
              "identificador" => "cesec90"
              "titulo" => "Leukemia patients"
            ]
            4 => array:2 [
              "identificador" => "cesec100"
              "titulo" => "Multivariate analysis"
            ]
            5 => array:2 [
              "identificador" => "cesec110"
              "titulo" => "Kaplan-Meier survival curves"
            ]
          ]
        ]
        4 => array:2 [
          "identificador" => "cesec120"
          "titulo" => "DISCUSSION"
        ]
        5 => array:2 [
          "identificador" => "xack639229"
          "titulo" => "ACKNOWLEDGMENTS"
        ]
        6 => array:1 [
          "titulo" => "REFERENCES"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-02-17"
    "fechaAceptado" => "2011-03-21"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "KEYWORDS"
          "identificador" => "xpalclavsec1582212"
          "palabras" => array:5 [
            0 => "Acute lymphoblastic leukemia"
            1 => "Juvenile idiopathic arthritis"
            2 => "Children"
            3 => "Limb pain"
            4 => "Thrombocytopenia"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:2 [
        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">OBJECTIVE&#58;</span><p id="spara110" class="elsevierStyleSimplePara elsevierViewall">To assess clinical and laboratory features that differentiate acute lymphoblastic leukemia from systemic juvenile idiopathic arthritis at disease onset&#46;</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">METHODS&#58;</span><p id="spara120" class="elsevierStyleSimplePara elsevierViewall">Fifty-seven leukemia patients with musculoskeletal involvement&#44; without blasts on peripheral blood and without glucocorticoid therapy at disease onset and 102 systemic juvenile idiopathic arthritis patients &#40;International League of Associations for Rheumatology criteria&#41; were retrospectively evaluated&#46; The following features were examined&#58; fever&#44; rheumatoid rash&#44; arthritis&#44; limb pain&#44; hepatomegaly&#44; splenomegaly&#44; pericarditis&#44; myocarditis&#44; pleuritis&#44; weight loss&#44; bleeding&#44; anemia&#44; leukopenia&#44; neutropenia&#44; thrombocytopenia&#44; erythrocyte sedimentation rate&#44; and lactic dehydrogenase levels&#46;</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">RESULTS&#58;</span><p id="spara130" class="elsevierStyleSimplePara elsevierViewall">The median age at disease onset was significantly higher in leukemia patients than in those with systemic-onset juvenile idiopathic arthritis &#40;5&#46;8 vs&#46; 3&#46;8 years&#41;&#46; In addition&#44; the frequencies of limb pain&#44; hepatomegaly&#44; weight loss and hemorrhagic manifestations were significantly higher in leukemia patients than in systemic-onset juvenile idiopathic arthritis patients &#40;70&#37; vs&#46; 1&#37;&#44; 54&#37; vs&#46; 32&#37;&#44; 30&#37; vs&#46; 8&#37;&#44; and 9&#37; vs&#46; 0&#37;&#44; respectively&#41;&#46; Likewise&#44; the frequencies of anemia&#44; leukopenia&#44; neutropenia&#44; thrombocytopenia and high lactic dehydrogenase levels were statistically higher in leukemia patients than in patients with systemic-onset juvenile idiopathic arthritis &#40;88&#37; vs&#46; 57&#37;&#44; 39&#37; vs&#46; 1&#37;&#44; 60&#37; vs&#46; 1&#37;&#44; 77&#37; vs&#46; 1&#37;&#44; and 56&#37; vs&#46; 14&#37;&#44; respectively&#41;&#46; Remarkably&#44; multivariate analysis revealed that limb pain &#40;OR &#61; 553&#59; 95&#37; CI &#61; 46&#46;48-6580&#46;42&#41; and thrombocytopenia &#40;OR &#61; 754&#46;13&#59; 95&#37; CI &#61; 64&#46;57-8806&#46;72&#41; were significant independent variables that differentiated leukemia from systemic-onset juvenile idiopathic arthritis&#46; The R2 of the Nagelkerke test was 0&#46;91&#44; and the Kaplan-Meier survival curves were similar for acute lymphoblastic leukemia patients with and without limb pain&#46;</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSION&#58;</span><p id="spara140" class="elsevierStyleSimplePara elsevierViewall">Our study emphasizes the importance of investigating leukemia in patients presenting with musculoskeletal manifestations and&#44; in particular&#44; limb pain associated with thrombocytopenia&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "ceabs10"
            "titulo" => "OBJECTIVE&#58;"
          ]
          1 => array:2 [
            "identificador" => "ceabs20"
            "titulo" => "METHODS&#58;"
          ]
          2 => array:2 [
            "identificador" => "ceabs30"
            "titulo" => "RESULTS&#58;"
          ]
          3 => array:2 [
            "identificador" => "ceabs40"
            "titulo" => "CONCLUSION&#58;"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:1 [
        "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">No potential conflict of interest was reported&#46;</p>"
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig1"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 334
            "Ancho" => 450
            "Tamanyo" => 22073
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        "descripcion" => array:1 [
          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">The Kaplan-Meier overall survival curves between leukemia patients without &#40;n &#61; 17&#41; and with limb pain &#40;n &#61; 40&#41; &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#46;8322&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig2"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 349
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            "Tamanyo" => 23359
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        "descripcion" => array:1 [
          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">The Kaplan-Meier overall survival curves between the whole group of leukemia patients &#40;n &#61; 190&#41; and leukemia patients with limb pain &#40;n &#61; 40&#41; &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#46;4875&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl1"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Values expressed in n &#40;&#37;&#41;&#46;</p>"
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                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">Variables&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">LEUKEMIA &#40;n &#61; 57&#41;&nbsp;\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">SoJIA &#40;n &#61; 102&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>-value&nbsp;\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">Arthralgia&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="center" valign="top">40 &#40;70&#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="center" valign="top">75 &#40;73&#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="char" valign="top">0&#46;7128&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="left" valign="top">Arthritis&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="center" valign="top">14 &#40;25&#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="center" valign="top">102 &#40;100&#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="char" valign="top">&#60;0&#46;0001&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="left" valign="top">Limb pain&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="center" valign="top">40 &#40;70&#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="center" valign="top">1 &#40;1&#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="char" valign="top">&#60;0&#46;0001&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="left" valign="top">Nighttime pain&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="center" valign="top">2 &#40;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="center" valign="top">2 &#40;2&#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="char" valign="top">0&#46;6183&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="left" valign="top">Fever&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="center" valign="top">39 &#40;68&#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="center" valign="top">102 &#40;100&#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="char" valign="top">&#60;0&#46;0001&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="left" valign="top">Hepatomegaly&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">31 &#40;54&#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="center" valign="top">33 &#40;32&#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="char" valign="top">0&#46;0075&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="left" valign="top">Splenomegaly&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="center" valign="top">26 &#40;46&#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="center" valign="top">31 &#40;30&#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="char" valign="top">0&#46;0602&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="left" valign="top">Adenomegaly&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="center" valign="top">12 &#40;21&#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="center" valign="top">47 &#40;46&#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="char" valign="top">0&#46;002&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="left" valign="top">Weight loss&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="center" valign="top">17 &#40;30&#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="center" valign="top">8 &#40;8&#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="char" valign="top">0&#46;0005&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="left" valign="top">Hemorrhagic manifestations&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="center" valign="top">5 &#40;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="center" valign="top">0 &#40;0&#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="char" valign="top">0&#46;0053&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="left" valign="top">Rheumatoid rash&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="center" valign="top">0 &#40;0&#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="center" valign="top">70 &#40;69&#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="char" valign="top">&#60;0&#46;0001&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="left" valign="top">Pericarditis&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="center" valign="top">0 &#40;0&#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="center" valign="top">16 &#40;16&#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="char" valign="top">0&#46;0006&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="left" valign="top" style="border-bottom: 2px solid black">Myocarditis&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="center" valign="top" style="border-bottom: 2px solid black">0 &#40;0&#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="center" valign="top" style="border-bottom: 2px solid black">8 &#40;8&#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="char" valign="top" style="border-bottom: 2px solid black">0&#46;0513&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Initial clinical manifestations in acute lymphoblastic leukemia patients vs&#46; systemic-onset juvenile idiopathic arthritis patients&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl2"
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        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spara60" class="elsevierStyleSimplePara elsevierViewall">Values expressed in median &#40;range&#41;&#44; WBC - white blood cell count&#44; LDH - lactic dehydrogenase&#46;</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">Variables&nbsp;\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">LEUKEMIA &#40;n &#61; 57&#41;&nbsp;\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">SoJIA &#40;n &#61; 102&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>-value&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="top">Hemoglobin &#40;g&#47;dl&#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="center" valign="top">7 &#40;3&#46;1&#8211;11&#46;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="center" valign="top">9&#46;7 &#40;5&#46;4&#8211;15&#46;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="center" valign="top">&#60;0&#46;0001&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="left" valign="top">WBC &#40;x10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span>&#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="center" valign="top">4&#46;6 &#40;0&#46;5&#8211;80&#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="center" valign="top">12&#46;3 &#40;3&#46;1&#8211;71&#46;8&#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="center" valign="top">&#60;0&#46;0001&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="left" valign="top">Neutrophils count &#40;x10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span>&#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="center" valign="top">0&#46;8 &#40;0&#8211;15&#46;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="center" valign="top">7&#46;3 &#40;0&#46;7&#8211;69&#46;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="center" valign="top">&#60;0&#46;0001&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="left" valign="top">Platelets count &#40;x10<span class="elsevierStyleSup">3</span>&#47;mm<span class="elsevierStyleSup">3</span>&#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="center" valign="top">56&#46;5 &#40;12&#46;8&#8211;499&#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="center" valign="top">490 &#40;70&#8211;1200&#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="center" valign="top">&#60;0&#46;0001&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="left" valign="top">LDH &#40;mg&#47;dl&#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="center" valign="top">822&#46;5 &#40;167&#8211;7900&#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="center" valign="top">305 &#40;13&#8211;4486&#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="center" valign="top">&#60;0&#46;0001&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="left" valign="top" style="border-bottom: 2px solid black">Uric acid &#40;mg&#47;dl&#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="center" valign="top" style="border-bottom: 2px solid black">4&#46;1 &#40;1&#46;3&#8211;14&#46;4&#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="center" valign="top" style="border-bottom: 2px solid black">3&#46;7 &#40;0&#8211;6&#46;1&#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="center" valign="top" style="border-bottom: 2px solid black">0&#46;2209&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:1 [
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                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">Variables&nbsp;\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">LEUKEMIA &#40;n &#61; 57&#41; N&#47;n &#40;&#37;&#41;&nbsp;\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">SoJIA &#40;n &#61; 102&#41; N&#47;n &#40;&#37;&#41;&nbsp;\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&nbsp;\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">Anemia&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="center" valign="top">50&#47;57&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="center" valign="top">58&#47;102&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="char" valign="top">&#60;0&#46;0001&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="left" valign="top">&#40;&#60;10&#160;g&#47;dl&#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="center" valign="top">&#40;88&#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="center" valign="top">&#40;57&#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></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">Leukopenia&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="center" valign="top">22&#47;57&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="center" valign="top">1&#47;102&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="char" valign="top">&#60;0&#46;0001&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="left" valign="top">&#40;&#60;4&#46;000&#47;mm<span class="elsevierStyleSup">3</span>&#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="center" valign="top">&#40;39&#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="center" valign="top">&#40;1&#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></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">Leukocytosis&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="center" valign="top">10&#47;57&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="center" valign="top">55&#47;102&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="char" valign="top">&#60;0&#46;0001&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="left" valign="top">&#40;&#62;12&#46;000&#47;mm<span class="elsevierStyleSup">3</span>&#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="center" valign="top">&#40;17&#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="center" valign="top">&#40;54&#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></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">Neutropenia&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="center" valign="top">34&#47;57&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="center" valign="top">1&#47;102&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="char" valign="top">&#60;0&#46;0001&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="left" valign="top">&#40;&#60;1&#46;000&#47;mm<span class="elsevierStyleSup">3</span>&#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="center" valign="top">&#40;60&#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="center" valign="top">&#40;1&#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></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">Thrombocytopenia&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="center" valign="top">44&#47;57&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="center" valign="top">1&#47;102&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="char" valign="top">&#60;0&#46;0001&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="left" valign="top">&#40;&#60;150&#46;000&#47;mm<span class="elsevierStyleSup">3</span>&#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="center" valign="top">&#40;77&#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="center" valign="top">&#40;1&#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></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">Thrombocytosis&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="center" valign="top">1&#47;57&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="center" valign="top">69&#47;102&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="char" valign="top">&#60;0&#46;0001&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="left" valign="top">&#40;&#62;400&#46;000&#47;mm<span class="elsevierStyleSup">3</span>&#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="center" valign="top">&#40;2&#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="center" valign="top">&#40;68&#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></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">High LDH&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="center" valign="top">32&#47;57&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="center" valign="top">6&#47;43&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="char" valign="top">&#60;0&#46;0001&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="left" valign="top">&#40;mg&#47;dl&#41; <a class="elsevierStyleCrossRef" href="#tfn4">&#42;</a>&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="center" valign="top">&#40;56&#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="center" valign="top">&#40;14&#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></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">High Uric acid&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
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                    0 => array:2 [
                      "titulo" => "Trends in childhood cancer incidence in the U&#46;S&#46; &#40;1992&#8211;2004&#41;"
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                          "etal" => false
                          "autores" => array:2 [
                            0 => """
                              AM Linabery \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              JA Ross \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1002/cncr.23169"
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                        "tituloSerie" => "Cancer"
                        "fecha" => "2008"
                        "volumen" => "112"
                        "paginaInicial" => "416"
                        "paginaFinal" => "432"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18074355"
                            "web" => "Medline"
                          ]
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                      "doi" => "10.1002/cncr.23169"
                      "WWW" => array:1 [
                        "link" => "10&#46;1002&#47;cncr&#46;23169"
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              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Trends in childhood cancer mortality&#8211;United States&#44; 1990&#8211;2004"
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                          "colaboracion" => "CDC"
                          "etal" => false
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                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "MMWR Morb Mortal Wkly Rep"
                        "fecha" => "2007"
                        "volumen" => "56"
                        "paginaInicial" => "1257"
                        "paginaFinal" => "1261"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18059256"
                            "web" => "Medline"
                          ]
                        ]
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                          "pii" => "S0015028220307111"
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              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Differential diagnosis of neoplastic and rheumatic diseases in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => """
                              E Musiej-Nowakowska \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              K Rostropowicz-Denisiewicz \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Scand J Rheumatology"
                        "fecha" => "1986"
                        "volumen" => "15"
                        "paginaInicial" => "124"
                        "paginaFinal" => "128"
                      ]
                    ]
                    1 => array:1 [
                      "WWW" => array:1 [
                        "link" => "10&#46;3109&#47;03009748609102077"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Malignancies in children who initially present with rheumatic complaints"
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                          "autores" => array:2 [
                            0 => """
                              DV Cabral \n
                              \t\t\t\t\t\t\t\t
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                            1 => """
                              LB Tucker \n
                              \t\t\t\t\t\t\t\t
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                          ]
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                        "tituloSerie" => "J Pediatr"
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                        "paginaInicial" => "53"
                        "paginaFinal" => "57"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9880449"
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                    0 => array:2 [
                      "titulo" => "Rheumatological manifestations of haematological diseases"
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                          "autores" => array:2 [
                            0 => """
                              S Menon \n
                              \t\t\t\t\t\t\t\t
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                              DA Isenberg \n
                              \t\t\t\t\t\t\t\t
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                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "1995"
                        "volumen" => "54"
                        "paginaInicial" => "787"
                        "paginaFinal" => "795"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7492215"
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                              \t\t\t\t\t\t\t\t
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                        "paginaInicial" => "481"
                        "paginaFinal" => "484"
                        "link" => array:1 [
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                      "WWW" => array:1 [
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                            0 => """
                              LM Campos \n
                              \t\t\t\t\t\t\t\t
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                              S Goldstein \n
                              \t\t\t\t\t\t\t\t
                              """
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                              \t\t\t\t\t\t\t\t
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                              \t\t\t\t\t\t\t\t
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                              V Odone Filho \n
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                        "paginaFinal" => "138"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18506321"
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                      "titulo" => "Bone pain as an initial symptom of childhood acute lymphoblastic leukemia&#58; Association with nearly normal hematologic indexes"
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                          "etal" => false
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                              OG Jonsson \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              P Sartain \n
                              \t\t\t\t\t\t\t\t
                              """
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                              JM Ducore \n
                              \t\t\t\t\t\t\t\t
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                              \t\t\t\t\t\t\t\t
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                        "tituloSerie" => "J Pediatr"
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                        "paginaInicial" => "233"
                        "paginaFinal" => "237"
                        "link" => array:1 [
                          0 => array:2 [
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                          "etal" => false
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                              TC Robazzi \n
                              \t\t\t\t\t\t\t\t
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                              JH Barreto \n
                              \t\t\t\t\t\t\t\t
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                              LR Silva \n
                              \t\t\t\t\t\t\t\t
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                              \t\t\t\t\t\t\t\t
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                              \t\t\t\t\t\t\t\t
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                        "paginaFinal" => "626"
                        "link" => array:1 [
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                      "titulo" => "Differentiation of systemic juvenile rheumatoid arthritis from acute leukemia near the onset of disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              BE Ostrov \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              DP Goldsmith \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              BH Athreya \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1016/s0022-3476(05)83543-7"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Pediatr"
                        "fecha" => "1993"
                        "volumen" => "122"
                        "paginaInicial" => "595"
                        "paginaFinal" => "598"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8463908"
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                          ]
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                      "doi" => "10.1016/s0022-3476(05)83543-7"
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                        "link" => "10&#46;1016&#47;S0022-3476&#40;05&#41;83543-7"
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              "identificador" => "bib11"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A multicenter case-control study on predictive factors distinguishing childhood leukemia from juvenile rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => """
                              OY Jones \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              CH Spencer \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              SL Bowyer \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              PB Dent \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              BS Gottlieb \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              CE Rabinovich \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatrics"
                        "fecha" => "2006"
                        "volumen" => "117"
                        "paginaInicial" => "840"
                        "paginaFinal" => "844"
                        "itemHostRev" => array:3 [
                          "pii" => "S0015028220327163"
                          "estado" => "S300"
                          "issn" => "00150282"
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                      ]
                    ]
                    1 => array:1 [
                      "WWW" => array:1 [
                        "link" => "10&#46;1542&#47;peds&#46;2005-1515"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib12"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Juvenile idiopathic arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => """
                              A Ravelli \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              A Martini \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(07)60363-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2007"
                        "volumen" => "369"
                        "paginaInicial" => "767"
                        "paginaFinal" => "778"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17336654"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                    1 => array:2 [
                      "doi" => "10.1016/S0140-6736(07)60363-8"
                      "WWW" => array:1 [
                        "link" => "10&#46;1016&#47;S0140-6736&#40;07&#41;60363-8"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib13"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Macrophage activation syndrome associated with systemic juvenile idiopathic arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              CA Silva \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              CH Silva \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              TC Robazzi \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              AP Lotito \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              A Mendroni Junior \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              CM Jacob \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Pediatr &#40;Rio J&#41;"
                        "fecha" => "2004"
                        "volumen" => "80"
                        "paginaInicial" => "517"
                        "paginaFinal" => "522"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15622430"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib14"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "International League of Associations for Rheumatology classification of juvenile idiopathic arthritis&#58; second revision&#44; Edmonton&#44; 2001"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              RE Petty \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              TR Southwood \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              P Manners \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              J Baum \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              DN Glass \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              J Goldenberg \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "J Rheumatol"
                        "fecha" => "2004"
                        "volumen" => "31"
                        "paginaInicial" => "390"
                        "paginaFinal" => "392"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14760812"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673619306907"
                          "estado" => "S300"
                          "issn" => "01406736"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The adverse effect of prolonged prednisolone pretreatment in children with acute lymphoblastic leukemia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => """
                              T R&#233;v&#233;sz \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              G Kardos \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              P Kajt&#225;r \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              D Schuler \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1002/1097-0142(19850415)55:8<1637::aid-cncr2820550804>3.0.co;2-h"
                      "Revista" => array:7 [
                        "tituloSerie" => "Cancer"
                        "fecha" => "1985"
                        "volumen" => "55"
                        "paginaInicial" => "1637"
                        "paginaFinal" => "1640"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3856464"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0015028218304266"
                          "estado" => "S300"
                          "issn" => "00150282"
                        ]
                      ]
                    ]
                    1 => array:2 [
                      "doi" => "10.1002/1097-0142(19850415)55:8<1637::aid-cncr2820550804>3.0.co;2-h"
                      "WWW" => array:1 [
                        "link" => "10&#46;1002&#47;1097-0142&#40;19850415&#41;55&#58;8&#60;1637&#58;&#58;AID-CNCR2820550804&#62;3&#46;0&#46;CO&#59;2-H"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib16"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cancer incidence among children and adolescents in Brazil&#58; first report of 14 population-based cancer registries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              B de Camargo \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              M de Oliveira Santos \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              MS Rebelo \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              R de Souza Reis \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              S Ferman \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              CP Noronha \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1002/ijc.24799"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Cancer"
                        "fecha" => "2010"
                        "volumen" => "126"
                        "paginaInicial" => "715"
                        "paginaFinal" => "720"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19642142"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                    1 => array:2 [
                      "doi" => "10.1002/ijc.24799"
                      "WWW" => array:1 [
                        "link" => "10&#46;1002&#47;ijc&#46;24799"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Arthritis as a presenting manifestation of malignancy in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => """
                              J Schaller \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1016/s0022-3476(72)80108-2"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Pediatr"
                        "fecha" => "1972"
                        "volumen" => "81"
                        "paginaInicial" => "793"
                        "paginaFinal" => "797"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4561480"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                    1 => array:2 [
                      "doi" => "10.1016/s0022-3476(72)80108-2"
                      "WWW" => array:1 [
                        "link" => "10&#46;1016&#47;S0022-3476&#40;72&#41;80108-2"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib18"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acute leukemia presenting as arthritis in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => """
                              FT Saulsbury \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              H Sabio \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Pediatr"
                        "fecha" => "1985"
                        "volumen" => "24"
                        "paginaInicial" => "625"
                        "paginaFinal" => "628"
                      ]
                    ]
                    1 => array:1 [
                      "WWW" => array:1 [
                        "link" => "10&#46;1177&#47;000992288502401103"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib19"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnosis of malignancies in children with musculoskeletal complaints"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => """
                              M Gon&#231;alves \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              MT Terreri \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              CM Barbosa \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              CA Len \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              L Lee \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              MO Hil&#225;rio \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1590/s1516-31802005000100005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Sao Paulo Med J"
                        "fecha" => "2005"
                        "volumen" => "123"
                        "paginaInicial" => "21"
                        "paginaFinal" => "23"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15821811"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                    1 => array:2 [
                      "doi" => "10.1590/s1516-31802005000100005"
                      "WWW" => array:1 [
                        "link" => "10&#46;1590&#47;S1516-31802005000700016"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib20"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The discriminating value of serum lactate dehydrogenase levels in children with malignant neoplasms presenting as joint pain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              M Wallendal \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              L Stork \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              R Hollister \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archpedi.1996.02170260074012"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Pediatr Adolesc Med"
                        "fecha" => "1996"
                        "volumen" => "150"
                        "paginaInicial" => "70"
                        "paginaFinal" => "73"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8542010"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib21"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Childhood leukaemia masquerading as juvenile idiopathic arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:5 [
                            0 => """
                              MJ Murray \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              T Tang \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              C Ryder \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              D Mabin \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              JC Nicholson \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.329.7472.959"
                      "Revista" => array:7 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "2004"
                        "volumen" => "329"
                        "paginaInicial" => "959"
                        "paginaFinal" => "961"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15499113"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673620326672"
                          "estado" => "S300"
                          "issn" => "01406736"
                        ]
                      ]
                    ]
                    1 => array:2 [
                      "doi" => "10.1136/bmj.329.7472.959"
                      "WWW" => array:1 [
                        "link" => "10&#46;1136&#47;bmj&#46;329&#46;7472&#46;959"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib22"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predictive plain X-ray findings in distinguishing early stage acute lymphoblastic leukemia from juvenile idiopathic arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => """
                              F Tafaghodi \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              Y Aghighi \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              H Rokni Yazdi \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              M Shakiba \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              A Adibi \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1007/s10067-009-1221-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Rheumatol"
                        "fecha" => "2009"
                        "volumen" => "28"
                        "paginaInicial" => "1253"
                        "paginaFinal" => "1258"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19621208"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                    1 => array:2 [
                      "doi" => "10.1007/s10067-009-1221-0"
                      "WWW" => array:1 [
                        "link" => "10&#46;1007&#47;s10067-009-1221-0"
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                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib23"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acute lymphoblastic leukemia masquerading as juvenile rheumatoid arthritis&#58; diagnostic pitfall and association with survival"
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                          "autores" => array:4 [
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                              RK Marwaha \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              KP Kulkarni \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              D Bansal \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              A Trehan \n
                              \t\t\t\t\t\t\t\t
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                        "paginaFinal" => "254"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19727722"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Juvenile idiopathic arthritis&#58; state of the art and future perspectives"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => """
                              A Martini \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              DJ Lovell \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1136/ard.2010.133033"
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                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "2010"
                        "volumen" => "69"
                        "paginaInicial" => "1260"
                        "paginaFinal" => "1263"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20525835"
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                        "link" => "10&#46;1136&#47;ard&#46;2010&#46;133033"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Interleukin 18 as a marker of disease activity and severity in patients with juvenile idiopathic arthritis"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => """
                              AP Lotito \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              A Campa \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              CA Silva \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              MH Kiss \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              SB Mello \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Rheumatol"
                        "fecha" => "2007"
                        "volumen" => "34"
                        "paginaInicial" => "823"
                        "paginaFinal" => "830"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17343316"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Macrophage activation syndrome associated with etanercept in a child with systemic onset juvenile idiopathic arthritis"
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                              EA N&#225;dia \n
                              \t\t\t\t\t\t\t\t
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                            1 => """
                              JF Carvalho \n
                              \t\t\t\t\t\t\t\t
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                            2 => """
                              E Bonf&#225; \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              AP Lotito \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              CA Silva \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Isr Med Assoc J"
                        "fecha" => "2009"
                        "volumen" => "11"
                        "paginaInicial" => "635"
                        "paginaFinal" => "636"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20077954"
                            "web" => "Medline"
                          ]
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                          "pii" => "S0015028221021555"
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                          "issn" => "00150282"
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                  ]
                ]
              ]
            ]
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              "identificador" => "bib27"
              "etiqueta" => "27"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Quality of life evaluation in children and adolescents with chronic and&#47;or incapacitating diseases&#58; a Brazilian study"
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                            0 => """
                              E Kuczynski \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              CA Silva \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              LM Crist&#243;fani \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              MH Kiss \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              V Odone Filho \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              FB Assump&#231;&#227;o Jr \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1016/s1695-4033(03)78120-x"
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                        "tituloSerie" => "An Pediatr &#40;Barc&#41;"
                        "fecha" => "2003"
                        "volumen" => "58"
                        "paginaInicial" => "550"
                        "paginaFinal" => "555"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12781110"
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                          "pii" => "S0002937817309456"
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                        "link" => "10&#46;1157&#47;13048092"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Preliminary diagnostic guidelines for macrophage activation syndrome complicating systemic juvenile idiopathic arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => """
                              A Ravelli \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              S Magni-Manzoni \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              A Pistorio \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              C Besana \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              T Foti \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              N Ruperto \n
                              \t\t\t\t\t\t\t\t
                              """
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                      ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.jpeds.2004.12.016"
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                        "volumen" => "146"
                        "paginaInicial" => "598"
                        "paginaFinal" => "604"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15870661"
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        "texto" => "<p id="para330" class="elsevierStylePara elsevierViewall">This study was sponsored by Conselho Nacional de Desenvolvimento Cient&#237;fico - CNPQ &#40;300248&#47;2008-3 to CAS&#41; and by Federico Foundation to CAS&#46; We thank Prof&#46; Ulysses D&#243;ria-Filho for statistical support&#46;</p>"
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Article information

ISSN: 18075932
Original language: English

DOI:10.1590/S1807-59322011001000001

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Year/Month	Html	Pdf	Total

2024 November	10	0	10
2024 October	45	18	63
2024 September	53	16	69
2024 August	44	19	63
2024 July	36	22	58
2024 June	40	8	48
2024 May	36	15	51
2024 April	39	11	50
2024 March	49	15	64
2024 February	42	16	58
2024 January	28	13	41
2023 December	25	22	47
2023 November	32	20	52
2023 October	27	15	42
2023 September	42	23	65
2023 August	23	10	33
2023 July	22	18	40
2023 June	34	14	48
2023 May	44	4	48
2023 April	41	1	42
2023 March	28	4	32
2023 February	23	2	25
2023 January	17	8	25
2022 December	26	3	29

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