Original article
Chronic brain damage in sickle cell disease and its relation with quality of life
Lesión crónica cerebral en la anemia falciforme y su relación con la calidad de vida
Elena Celaa,
, Ana G. Vélezb, Alejandra Aguadoc, Gabriela Medínd, José M. Bellónd, Cristina Beléndeza
Corresponding author
a Hematología Pediátrica, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
b Estudiante de pregrado de Medicina, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
c Servicio de Radiodiagnóstico Pediátrico, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
d Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
Read
4
Timeswas read the article
2
Total PDF
2
Total HTML
Share statistics
array:24 [ "pii" => "S2387020616307896" "issn" => "23870206" "doi" => "10.1016/j.medcle.2016.12.041" "estado" => "S300" "fechaPublicacion" => "2016-12-16" "aid" => "3742" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2016" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Med Clin. 2016;147:531-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0025775316303761" "issn" => "00257753" "doi" => "10.1016/j.medcli.2016.07.028" "estado" => "S300" "fechaPublicacion" => "2016-12-16" "aid" => "3742" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Med Clin. 2016;147:531-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 11 "formatos" => array:2 [ "HTML" => 9 "PDF" => 2 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original</span>" "titulo" => "Lesión crónica cerebral en la anemia falciforme y su relación con la calidad de vida" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "531" "paginaFinal" => "536" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Chronic brain damage in sickle cell disease and its relation with quality of life" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 926 "Ancho" => 1650 "Tamanyo" => 71160 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Selección de pacientes.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Elena Cela, Ana G. Vélez, Alejandra Aguado, Gabriela Medín, José M. Bellón, Cristina Beléndez" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Elena" "apellidos" => "Cela" ] 1 => array:2 [ "nombre" => "Ana G." "apellidos" => "Vélez" ] 2 => array:2 [ "nombre" => "Alejandra" "apellidos" => "Aguado" ] 3 => array:2 [ "nombre" => "Gabriela" "apellidos" => "Medín" ] 4 => array:2 [ "nombre" => "José M." "apellidos" => "Bellón" ] 5 => array:2 [ "nombre" => "Cristina" "apellidos" => "Beléndez" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020616307896" "doi" => "10.1016/j.medcle.2016.12.041" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616307896?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775316303761?idApp=UINPBA00004N" "url" => "/00257753/0000014700000012/v1_201612100119/S0025775316303761/v1_201612100119/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2387020616308014" "issn" => "23870206" "doi" => "10.1016/j.medcle.2016.12.051" "estado" => "S300" "fechaPublicacion" => "2016-12-16" "aid" => "3799" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Clin. 2016;147:537-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1 "HTML" => 1 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Brief report</span>" "titulo" => "Nordic walking for cardiovascular prevention in patients with ischaemic heart disease or metabolic syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "537" "paginaFinal" => "539" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Marcha nórdica para prevención cardiovascular en pacientes con cardiopatía isquémica crónica o síndrome metabólico" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 649 "Ancho" => 1761 "Tamanyo" => 68851 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient inclusion flowchart.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Cristina Vehí, Carles Falces, Miquel Àngel Sarlat, Ana Gonzalo, Rut Andrea, Marta Sitges" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Cristina" "apellidos" => "Vehí" ] 1 => array:2 [ "nombre" => "Carles" "apellidos" => "Falces" ] 2 => array:2 [ "nombre" => "Miquel Àngel" "apellidos" => "Sarlat" ] 3 => array:2 [ "nombre" => "Ana" "apellidos" => "Gonzalo" ] 4 => array:2 [ "nombre" => "Rut" "apellidos" => "Andrea" ] 5 => array:2 [ "nombre" => "Marta" "apellidos" => "Sitges" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775316305024" "doi" => "10.1016/j.medcli.2016.09.041" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775316305024?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616308014?idApp=UINPBA00004N" "url" => "/23870206/0000014700000012/v1_201702040025/S2387020616308014/v1_201702040025/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020616307884" "issn" => "23870206" "doi" => "10.1016/j.medcle.2016.12.040" "estado" => "S300" "fechaPublicacion" => "2016-12-16" "aid" => "3738" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Med Clin. 2016;147:523-30" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Comparison of the Canadian CT head rule and the New Orleans criteria in patients with minor head injury in a Spanish hospital" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "523" "paginaFinal" => "530" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comparación de la regla canadiense y los criterios de New Orleans en el traumatismo craneal leve en un hospital español" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1576 "Ancho" => 1580 "Tamanyo" => 103177 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ROC curve for significant multivariate model (GCS, vomiting, age ≥65 years, and headache). Goodness of fit test of Hosmer and Lemeshow <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.21, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.696; Wald statistic<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>90, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001; coefficient of determination <span class="elsevierStyleItalic">r</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.335; Cox–Snell coefficient of determination: 0.234, Nagelkerke coefficient of determination: 0.44 and ROC curve, area under the curve (%) 95% CI: 87% (78.2–96).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Joaquín Valle Alonso, Francisco Javier Fonseca del Pozo, Manuel Vaquero Álvarez, Elisa Lopera Lopera, Marisol Garcia Segura, Ricardo García Arévalo" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Joaquín" "apellidos" => "Valle Alonso" ] 1 => array:2 [ "nombre" => "Francisco Javier" "apellidos" => "Fonseca del Pozo" ] 2 => array:2 [ "nombre" => "Manuel" "apellidos" => "Vaquero Álvarez" ] 3 => array:2 [ "nombre" => "Elisa" "apellidos" => "Lopera Lopera" ] 4 => array:2 [ "nombre" => "Marisol" "apellidos" => "Garcia Segura" ] 5 => array:2 [ "nombre" => "Ricardo" "apellidos" => "García Arévalo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775316303724" "doi" => "10.1016/j.medcli.2016.07.024" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775316303724?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616307884?idApp=UINPBA00004N" "url" => "/23870206/0000014700000012/v1_201702040025/S2387020616307884/v1_201702040025/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Chronic brain damage in sickle cell disease and its relation with quality of life" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "531" "paginaFinal" => "536" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Elena Cela, Ana G. Vélez, Alejandra Aguado, Gabriela Medín, José M. Bellón, Cristina Beléndez" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Elena" "apellidos" => "Cela" "email" => array:1 [ 0 => "elena.cela@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ana G." "apellidos" => "Vélez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Alejandra" "apellidos" => "Aguado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Gabriela" "apellidos" => "Medín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "José M." "apellidos" => "Bellón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "Cristina" "apellidos" => "Beléndez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Hematología Pediátrica, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Estudiante de pregrado de Medicina, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico Pediátrico, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesión crónica cerebral en la anemia falciforme y su relación con la calidad de vida" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 926 "Ancho" => 1650 "Tamanyo" => 63271 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient selection.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sickle cell anemia (SCA) is an inherited disease characterized by chronic haemolytic anemia and vascular occlusions, which cause acute pain by ischemia, and a chronic progressive organ damage. The most devastating complication is <span class="elsevierStyleItalic">acute cerebrovascular accident</span> (ACVA) by large vessel involvement. Primary prevention of the same is done by assessing its risk according to cerebral blood flow measured by transcranial Doppler ultrasound (TCDUS). There is also a brain microvasculature disorder, which, in the majority of cases, does not present symptoms (they are called silent infarctions), but appears to be associated with impaired cognitive function.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1–3</span></a> Overall, cerebrovascular disease produces the lowest IQs if there is ACVA, intermediate values if silent infarctions are present, and figures around 90 even in children without abnormalities in neuroimaging.</p><p id="par0010" class="elsevierStylePara elsevierViewall">SCA is characterized by the presence of hemoglobin S (HbS), resulting from the substitution of valine by glutamic acid at amino acid position 6 of β globin chain. The presence of HbS causes an Hb tetramer (alpha2/betaS2) which is insoluble when deoxygenated, causing the deformation of the erythrocyte until it acquires a sickle shape, decreasing the elasticity of the same. The disease may be revealed through the presence of homozygous HbS (SS) or its heterozygous combination with another mutation of the β globin chain (HbS-beta thalassemia, HbSC).<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">4–6</span></a> HbS gene is distributed worldwide, most often in sub-Saharan Africa and Central and South America. This high prevalence in certain regions of the world seems to reflect the protective effect of the mutation against <span class="elsevierStyleItalic">Plasmodium falciparum</span>. It is the most common hemoglobinopathy in the United States, with an incidence of one case per 625 live births. In Spain, the prevalence has increased in the last 2 decades by increased immigration, and in some communities, there has been an incidence of one case per 5000 newborns.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the neonatal screening, it can be diagnosed by chromatography through the heel prick test or when the clinical signs and symptoms appear, at later ages.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> The universal new-born screening was introduced in the Community of Madrid in 2003, in the Basque Country in 2011, Valencia in 2012, and the rest of the Spanish regions progressively from 2015.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Treatment is based on health education for recognizing warning symptoms, vaccination against encapsulated bacteria, penicillin prophylaxis, transfusions in selected situations, stimulating production of fetal hemoglobin and, in selected cases, hematopoietic stem cell transplantation from matched sibling.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Silent infarcts are a major manifestation of cerebral vascular disease in these patients, which alter neurocognitive function.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> They are detected in magnetic resonance imaging (MRI) using the sequences T1, T2 and FLAIR, and it includes lesions related to leukoencephalopathy, infarction and encephalomalacia.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a> They are the result of occlusion of small vessels, and usually appear in the arterial border zones. Therefore, the terminology used is misleading, because although it alludes to its imaging diagnosis without obvious neurological symptoms, the neurocognitive test abnormalities can be remarkable, and the association with a subsequent frank stroke seems clear.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> Neurocognitive impairment and poor school performance may be multifactorial, including objective brain injuries and other psychosocial factors,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> as deterioration has also been detected in young children in whom illness severity was not yet a determining factor.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> In the United States, the socioeconomic status and a troublesome family environment is associated with low academic level.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The aim of this paper is to describe student performance in our healthcare environment of a group of children with SCA that may be associated with chronic brain injury, reflected in clinical and laboratory parameters, alterations in neuroimaging or socio-cultural problems, and also evaluating the quality of life. The hypothesis is that if changes in school and quality of life occur early, before they are detected in the objective imaging or clinical tests, other factors must be present, apart from the disease itself.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and method</span><p id="par0035" class="elsevierStylePara elsevierViewall">Cross-sectional study in November 2015 at a single university hospital. Patients included were a cohort of children with SCA under follow-up since their diagnosis in the Pediatric Haemoglobinopathies Unit that met the following criteria at the study's cut-off point: age between 2 and 18 years, have gone at least once to medical consultation in the last year, to be alive, informed consent from parents and accepting to answer a survey. The study was approved by the Ethics Committee of the center.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Out of a total of 201 patients diagnosed with SCA, 60 children met the inclusion criteria (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Exclusions were due to death, not meeting the age criteria or because the family could not be traced (54%). Of these, 15% had returned to their home countries and the rest did not respond to calls. There were no differences between the latter and those selected in terms of sex, age, time of diagnosis or genotype. A review of electronic medical records was performed by selecting the following variables in the case report form: demographic, neurological examination, laboratory parameters, complications of the disease, brain MRI, TCDUS, household survey on socioeconomic status and academic performance, and PedsQL quality of life (<a class="elsevierStyleCrossRef" href="#sec0030">Appendix A</a>). School failure was defined as a repetition of the school year or need for school support. Radiographic images had already been reported, nevertheless, they were reviewed by a single radiologist from the Radiodiagnosis Service who had been trained specifically for this purpose in order to reclassify them as normal or not, TCDUS being pathological according to the STOP study<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> and MRIs that showed the presence of silent infarcts or large vessel infarction.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> Nocturnal hypoxemia was evaluated by monitoring continuous nocturnal pulse oximetry, and, if the results were questionable, with polysomnography with 13-lead EEG bipolar recording of the EOG, EMG of right deltoid muscle, oronasal airflow and thoracoabdominal respiratory effort, and oxygen saturation.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> Quality of life was measured by the PedsQL questionnaire, version 4.0, and was answered verbally by the patient's parents. A score below or equal to 70 points was considered pathological.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">17,18</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The results of the continuous variables are presented by the mean and range (minimum and maximum value). For categorical variables, the results are shown in frequencies and percentages. Numeric variables with non-normal distribution are presented by their median and interquartile range (25th percentile, 75th percentile). The normality analysis was performed with the Kolmogorov–Smirnov test. To study the differences in medians of two groups, as in the case of Hb, nonparametric tests (Mann–Whitney) were used, as they do not require normal distribution of data and are the most suitable for the size of the groups. The association between qualitative variables was studied using Pearson's chi-square test or Fisher's exact test. Statistical analysis was performed with the IBM SPSS program for Windows, version 21.0 (IBM Corp., Armonk, NY, USA). All statistical tests were bilateral and those results with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 were considered statistically significant.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">Of the 60 selected patients, the boy/girl ratio was 1.3/1. The median current age was 6.8 years (range 2–17 years), and age at diagnosis of 0 years (mean 1.27, range 0–12 years). 78% were diagnosed by the heel prick test for neonatal screening of sickle cell disease in the autonomous community of the research center, while in the rest of cases, the diagnosis was made later by electrophoresis, either due to the appearance of symptoms compatible with the disease, either because going to the primary care clinic for a comprehensive check-up after they arrived in Spain due to immigration. Genotype distribution can be found in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The median follow-up time reached 6 years (1–15). The patients’ family origin was Africa 60%, Latin America 35%, India 1.6% and in 0.3% a parent came from Africa and another from Latin America. 55% of parents were born in Spanish-speaking countries.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Only 60% were enrolled in the school-year corresponding to their age, of whom 33% needed additional support by teachers. 22% repeated a school year sometime, and 77% of school-year repeaters still needed support. 18% were not attending school by family decision, not being yet under compulsory schooling. Putting the children who had repeated a grade and those who needed support together (51% of those going to school), no difference was found when compared with those without school difficulties in terms of age at the time of diagnosis, more than 2 admissions, neurological deficits, having experienced some acute chest syndrome (ACS), lung disease, pathological MRI or TCDUS, only primary education level in the family, quality of life or unemployment situation. The number of cases of school failure was greater in the presence of ACVA (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.076) and single-parent family (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.085), and a statistically significant difference was found in terms of nocturnal hypoxemia (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.029). Logistic regression of the school failure variable showed no significance in the quantitative variables studied, except in the school PedsQL (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.039; OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.5, 95% CI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.09–27.99).</p><p id="par0065" class="elsevierStylePara elsevierViewall">The household consisted of parents and children in 70% of cases. In the remaining 30%, the mother was the primary caregiver, with support from other family members in 89% of cases. The highest level of education completed by at least one of the two parents was a university degree in 16%, 36% high school, vocational training 8%, secondary education 21% and primary education 16%. The level of employment of the parents was divided into 27% of children with both parents working, working one of the 2 in 35% of cases, unemployed with unemployment benefits 13%, with 18% of families receiving the basic guaranteed income as the only income, and 6% not receiving any financial allowance.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The median number of baseline Hb was 8.6<span class="elsevierStyleHsp" style=""></span>g/dl (range 5.8–11.7). The median number of admissions in the last year was 4 episodes (range 0–28), resulting in 0.86 admissions per patient and follow-up year from diagnosis (0–5). 8% had ACS at some point in their lives, resulting in an average annual incidence of 0.11 ACS/follow-up year (median 0, range 0–1). 6.7% of patients presented an ACVA in their history, of which only half had a pathological neurological examination as sequela. 11% of patients had some sort of lung disease, either of an obstructive type (8%) or mixed (3%). The existence of nocturnal hypoxemia was assessed in 24 patients and was found pathological in 8%. Hematopoietic stem cell transplantation was performed in 11%.</p><p id="par0075" class="elsevierStylePara elsevierViewall">TCDUS could be completed in 80% of patients, with 4% being pathological. Brain MRI was performed in 60% of children, and was pathological in 16%. The comparative chi-square test between a pathological MRI and other variables showed <span class="elsevierStyleItalic">p</span> values of 0.064 with abnormal TCDUS and 0.05 with school PedsQL<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>70, and non-significant with the number of ACS, lung disease, transplant, Hb levels and other areas of PedsQL.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The PedsQL questionnaire, version 4.0, was conducted in all patients and the pathological results are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, analyzed by various age groups. No statistically significant differences were found in several parameters among children diagnosed before 2 years of age and, therefore, with a closer follow-up, and those diagnosed later (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), or with other sociodemographic variables, or with schooling difficulties. Significant differences were found between physical PedsQL<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>70 and having experienced an ACVA (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.042) or pneumopathy (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.022). In the pathological emotional domain, significance was found in the presence of lung disease (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.049), and in the social domain with a pathological neurological examination (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.003) and ACVA (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002). No differences were found between pathological PedsQL of school and psychosocial areas with other parameters, except for a trend between the latter and neurological deficit (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.057).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The increase in the prevalence of SCA in Spain has occurred in the past 2 decades and it has led to the adequacy of essential health services in order to provide the proper care from a diagnostic, clinical and therapeutic point of view. In this sense, a wide response has been observed from different institutions regarding the implementation of neonatal screening, the development of clinical practice guidelines, patient registration and treatment homogenization with what has been applied in other countries with more tradition in addressing this sickness. However, the healthcare characteristics of immigrants, access to educational and cultural resources, and psychosocial integration have unique aspects in each country, so this work provides previously unknown data on a large group of patients.</p><p id="par0090" class="elsevierStylePara elsevierViewall">We describe clinical, laboratory, socio-cultural parameters, alterations of neuroimaging and quality of life of children with SCA under follow-up in our healthcare environment. Apart from the predictable complications of the disease, half of the children experience schooling difficulties and impaired quality of life. There have been attempts to support the hypothesis of linking these variables with objective clinical or imaging parameters, or failing that, to seek other factors which are not related to the disease itself. The sample size is the main limitation on the comparison of the factors studied.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The number of children who still need school support while being in their school year (12 of 36 attending their school year) is something worth mentioning. If these are added to the number of those who need to repeat the school year (13), and deducting the unschooled due to being too young, results in 51% patients having learning difficulties. Given the low median age, this figure is expected to increase over time taking into consideration subsequent school difficulties and persistence of disease-related chronic vascular injury. Schooling problems may be due to neurocognitive impairment resulting from a late diagnosis of the disease that prevented an early clinical approach, socioeconomic barriers and, finally, episodes secondary to the disease itself.</p><p id="par0100" class="elsevierStylePara elsevierViewall">As for early diagnosis, the low median age at the time of detection of SCA by the heel prick test in new-borns reflects the rapid response given concerning the care of these children. There are no differences between the schooling difficulties found among those diagnosed at birth or those with a late diagnosis. Therefore, we assume that this factor should not affect the occurrence of a chronic brain injury or a low quality of life.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In relation to social and/or economic aspects, we analyzed factors such as immigration, mother tongue, employment and educational level of parents. Most parents are from Africa, with the consequent difficulties of cultural, social and economic integration. The language barrier is an added difficulty, which is softened in the case of those who come from Spanish-speaking America or Equatorial Guinea. No differences were found between poor school performance or a low quality of life in any of these parameters mentioned, which may indicate that integration is acceptable or that the follow-up time or sample size are not enough.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The third possibility that can influence school performance is comorbidity due to the typical complications of the disease. Of these, only nocturnal hypoxemia is significant, unlike other parameters that could reflect greater clinical severity, such as more than 2 hospital admissions, ACS, lung disease or neurological involvement. Of the 10 children with pathological MRI, 4 had large vessel infarction, although without observable neurological sequelae in half of them, and 6 silent infarcts. However, a <span class="elsevierStyleItalic">p</span> value of 0.05 is documented in these children with pathological findings in the school domain of the PedsQL, although only two patients showed abnormalities in the neurological examination. This would confirm, if this trend continues, that silent infarcts are not really silent, and that brain injury adversely affects the quality of life. If so, MRI scans should be recommended early in children even if they are asymptomatic, and take an active therapeutic attitude when there is evidence of white matter alterations. In this objective parameter, the absence of a relationship between a pathological MRI and other parameters of alleged severity of the disease, such as ACS, lung disease, frequent admissions or more severe anemia is repeated. Comparison with abnormal TCDUS is not significant, probably because the cohort follow-up is close and whenever there is an abnormal ultrasound, infarction prophylaxis is immediately adopted with hypertransfusion regimens.</p><p id="par0115" class="elsevierStylePara elsevierViewall">No statistically significant differences were found between those with and those without learning difficulties in the clinical and imaging parameters studied, which may reflect that, regardless of whether the disease causes admissions or motor deficit or lung disease, or whether the diagnosis was made at birth or even when the neuroimaging tests are normal, the disease is sufficiently silent to affect school performance without the doctors being able to foresee it, that an adequate sample size has not been reached, or that there are other sociocultural confusion factors independent from the disease studied.</p><p id="par0120" class="elsevierStylePara elsevierViewall">A more intensive psychosocial protocol would be required, with extensive neurocognitive assessment that contributes to early detection of lesions and proper monitoring of these children. The tendency to the significance of the presence of ACVA, single parent family or significant nocturnal hypoxemia should not make us assume that if these problems are not present there will be no school difficulties. The compulsory school age is 6 years, but it is rare to find healthy children older than 2 years who do not attend nursery schools in Spain. However, 11 of our patients below the age of compulsory schooling were unschooled, possibly due to the parents’ unemployment and difficulties accessing social support systems to finance schooling. This is likely to involve a disadvantage in neurocognitive development with respect to their peers, added to the usual physiologic suffering. Anyway, it seems that neurocognitive impairment in this population begin to occur early in the first years of life and have multifactorial causes.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">15,19</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The quality of life as measured by the PedsQL shows pathological findings in all domains, which increase with age, although a low quality of life is even found among small children. Quality of life may not be normal, although there are no disease severity criteria, as one might think in the absence of hospital admissions or organic brain injury through MRI. The early care provided thanks to diagnosis in neonatal screening does not seem to make any difference regarding the need for school support, avoid repeating the school year, improve the quality of life, or not finding a pathological MRI. Therefore, although the diagnosis at birth has shown to prevent sepsis by antibiotic prophylaxis and immunizations, other apparently hidden parameters, such as cerebral microvasculature injury or quality of life do not seem to be prevented, since appropriate medical or cultural measures are not probably adopted.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> A confounding factor could be that the perception of parents about the quality of life of their children is worse than what is perceived by the children themselves, which has not been studied.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Our study provides a somewhat discouraging vision of the academic integration of children with SCA in our school system, although the limitations have to do with the fact that other more accurate tests have not been investigated, that the sample size is small and that a case-control study should be conducted to define precisely whether the problem exists. If children with SCA are assessed superficially, it may seem that the disease does not cause neurological damage in the early years, especially if the patient has not been admitted to hospital, has normal imaging tests and has not experienced respiratory problems. But, really, organ injuries begin from birth and the image of normality could be unreal. The variables that influence these results possibly include not only purely organic alterations in brain microvessels, but a wide combination of cultural, social, economic and language factors.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The power to take measures to deal with the disease from a medical point of view is in the hands of health professionals, but educational and social institutions should also get involved in order to meet other needs that affect this population group. To mention a few, we highlight the promotion of early schooling, specific educational and psychological support, socio-cultural integration of families, coordination between the education community, primary care, hospital and social workers, health education and early screening for neurocognitive impairment. We hope that future cohort follow-up studies expand the knowledge of neurocognitive impairment and quality of life associated with clinical parameters in our healthcare environment. It is essential to allow the possibility of early intensive medical treatment initiation with hydroxyurea, bone marrow transplant or other measures to prevent irreversible damage.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres797992" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec795982" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres797993" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec795981" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-03-14" "fechaAceptado" => "2016-07-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec795982" "palabras" => array:4 [ 0 => "Sickle cell anemia" 1 => "Quality of life" 2 => "Neurocognitive disorders" 3 => "Neuroimaging" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec795981" "palabras" => array:4 [ 0 => "Anemia de células falciformes" 1 => "Calidad de vida" 2 => "Trastornos neurocognitivos" 3 => "Neuroimagen" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sickle cell anemia causes progressive organ damage. The objective is to describe school performance of patients with sickle cell anemia and their clinical parameters and quality of life that may have an influence. The hypothesis is that if school alterations occur without other objective data, additional factors must be present besides the disease itself.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Transversal study performed in November 2015 considering analytical variables, complications and neuroradiological images of children with sickle cell anemia, and family survey on school performance and quality of life.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Median age was 6.8 years and 78% were diagnosed at birth. Sixty patients were included. School performance was altered in 51% of cases and was related to nocturnal hypoxemia. Acute stroke incidence was 6.7%. Transcranial ultrasound was abnormal in 4% of cases and magnetic resonance imaging in 16% of cases. Quality of life showed pathological findings in all areas and the low values increased proportionally in older ages. The stroke affected the physical and social sphere, and lung disease affected the physical and emotional spheres.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Poor school performance affects half of the patients and it is related to nocturnal hypoxemia, although other socio-cultural factors may have an influence. Quality of life is affected in most of these cases independently of academic results. The absence of alterations in neuroimaging or the apparent lack of severe clinical parameters do not mean that quality of life and schooling are normal.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La anemia falciforme provoca una lesión orgánica progresiva. El objetivo de este trabajo es describir el rendimiento escolar de pacientes con anemia falciforme y los parámetros clínicos y de calidad de vida que pueden influir. La hipótesis es que si las alteraciones escolares se presentan sin otros datos objetivos, factores añadidos deben concurrir aparte de la propia enfermedad.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal realizado en noviembre de 2015 considerando variables analíticas, complicaciones e imágenes neurorradiológicas de niños con anemia falciforme, y encuesta familiar sobre rendimiento escolar y calidad de vida.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 60 pacientes. La mediana de edad fue de 6,8 años, y el 78% se diagnosticaron al nacimiento. El rendimiento escolar estaba alterado en el 51% y se relacionó con hipoxemia nocturna. El accidente cerebrovascular se presentó en el 6,7%. La ecografía doppler transcraneal fue patológica en el 4% y la resonancia magnética en el 16%. La calidad de vida arrojó resultados patológicos en todas las esferas y aumentó la proporción con valores bajos a mayor edad. El accidente cerebrovascular afectó la esfera física-social, y la neumopatía, la física-emocional.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El fracaso escolar como expresión de lesión crónica cerebral en la anemia falciforme afecta a la mitad de los pacientes y se relaciona con hipoxemia nocturna, aunque otros factores de confusión socioculturales pueden influir. La calidad de vida está alterada en la mayoría de los niños, independientemente del retraso escolar. La ausencia de una lesión orgánica objetiva en la neuroimagen o de parámetros de gravedad clínica no implican que la calidad de vida o la escolarización sean normales.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cela E, Vélez AG, Aguado A, Medín G, Bellón JM, Beléndez C. Lesión crónica cerebral en la anemia falciforme y su relación con la calidad de vida. Med Clin (Barc). 2016;147:531–536.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:3 [ "etiqueta" => "Appendix A" "identificador" => "sec0030" "apendiceSeccion" => array:2 [ 0 => array:4 [ "apendice" => "<p id="par0145" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">School year: no repeater/repeater.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">School support: yes/no.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Household composition.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Country of origin of parents.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Highest level of education completed by main caregiver/s.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Employment status of main caregiver/s: work/unemployed/basic income/no income.</p></li></ul></p>" "etiqueta" => "A.1" "titulo" => "Household survey" "identificador" => "sec0035" ] 1 => array:5 [ "apendice" => "<p id="par0180" class="elsevierStylePara elsevierViewall">In the last four weeks, to what extent has the following been a problem for your child:</p> <p id="par0185" class="elsevierStylePara elsevierViewall">Physical domain:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">1.</span><p id="par0190" class="elsevierStylePara elsevierViewall">Walking/more than one block*</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">2.</span><p id="par0195" class="elsevierStylePara elsevierViewall">Run</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">3.</span><p id="par0200" class="elsevierStylePara elsevierViewall">Participate in active games or exercise</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">4.</span><p id="par0205" class="elsevierStylePara elsevierViewall">Take heavy objects</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">5.</span><p id="par0210" class="elsevierStylePara elsevierViewall">Bathing/Showering or bathing alone*</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">6.</span><p id="par0215" class="elsevierStylePara elsevierViewall">Help pick up their toys/at home*</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">7.</span><p id="par0220" class="elsevierStylePara elsevierViewall">Pain</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">8.</span><p id="par0225" class="elsevierStylePara elsevierViewall">Feeling tired</p></li></ul></p>" "etiqueta" => "A.2" "titulo" => "PedsQL version 4.0" "identificador" => "sec0040" "apendiceSeccion" => array:3 [ 0 => array:4 [ "apendice" => "<p id="par0230" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">1.</span><p id="par0235" class="elsevierStylePara elsevierViewall">Being afraid</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">2.</span><p id="par0240" class="elsevierStylePara elsevierViewall">Feeling sad</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">3.</span><p id="par0245" class="elsevierStylePara elsevierViewall">Getting angry</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">4.</span><p id="par0250" class="elsevierStylePara elsevierViewall">Having trouble to sleep</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">5.</span><p id="par0255" class="elsevierStylePara elsevierViewall">Being worried/about what might happen*</p></li></ul></p>" "etiqueta" => "A.2.1" "titulo" => "Emotional domain" "identificador" => "sec0045" ] 1 => array:4 [ "apendice" => "<p id="par0260" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">1.</span><p id="par0265" class="elsevierStylePara elsevierViewall">Play/interact with other children*</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2.</span><p id="par0270" class="elsevierStylePara elsevierViewall">Other kids do not want to play with him/her or be his/her friends*</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">3.</span><p id="par0275" class="elsevierStylePara elsevierViewall">Other kids tease him/her</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">4.</span><p id="par0280" class="elsevierStylePara elsevierViewall">Being able to do the same things as other children his age</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">5.</span><p id="par0285" class="elsevierStylePara elsevierViewall">Keep up with the other children when playing</p></li></ul></p>" "etiqueta" => "A.2.2" "titulo" => "Social domain" "identificador" => "sec0050" ] 2 => array:4 [ "apendice" => "<p id="par0290" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">1.</span><p id="par0295" class="elsevierStylePara elsevierViewall">Pay attention in class*</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">2.</span><p id="par0300" class="elsevierStylePara elsevierViewall">Forgetting things *</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">3.</span><p id="par0305" class="elsevierStylePara elsevierViewall">Doing the same tasks as his/her peers/Finish all the homework*</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">4.</span><p id="par0310" class="elsevierStylePara elsevierViewall">Not going to school because not feeling well</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">5.</span><p id="par0315" class="elsevierStylePara elsevierViewall">Not going to school for having to go to the doctor or hospital</p></li></ul></p> <p id="par0320" class="elsevierStylePara elsevierViewall">Psychosocial domain: mean of the emotional, social and school domains</p> <p id="par0325" class="elsevierStylePara elsevierViewall">*Patients older than 4 years.</p>" "etiqueta" => "A.2.3" "titulo" => "School domain" "identificador" => "sec0055" ] ] ] ] ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 926 "Ancho" => 1650 "Tamanyo" => 63271 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient selection.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Genotype \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of patients (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (81.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SBeta0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (5.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SBeta + \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (6.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (6.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1338481.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Genotype of patients with sickle cell anemia (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>60).</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Data expressed as n (%).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2–6 years<br>22 patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6–9 years<br>17 patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Over 9 years of age<br>21 patients \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Physical domain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (35.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (57.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Emotional domain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (27.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (41.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (52.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Social domain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (11.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (38.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">School domain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (9.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (11.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (57.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1338482.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Pathological results (≤70 points) in PedsQL questionnaire, version 4.0 (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>60).</p>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Before age 2, n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">After age 2, n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pathological MRI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (14.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (23.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.444 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Repeats school year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (19.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (30.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.268 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">School support \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (17.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (30.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.268 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PedsQL<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>70 physical% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (25.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (46.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.091 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PedsQL<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>70% emotional \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (36.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (53.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.147 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PedsQL<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>70 social% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (17.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (23.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.505 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PedsQL<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>70% school \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (34.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (61.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.079 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PedsQL<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>70% psychosocial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (27.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (23.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.884 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1338480.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Comparison between 0 children diagnosed before (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>47) or after 2 years of age (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>13).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ictus infantil y drepanocitosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Cela" 1 => "C. Beléndez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "titulo" => "Ictus en la infancia" "fecha" => "2012" "editorial" => "Monografías en Neuropediatría de la SENEP" "editorialLocalizacion" => "Viguera" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0105" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neurocognitive deficits in children with sickle cell disease: a comprehensive profile" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.T. Hijmans" 1 => "K. Fijnvandraat" 2 => "M.A. Grootenhuis" 3 => "N. van Geloven" 4 => "H. Heijboer" 5 => "M. Peters" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/pbc.22879" "Revista" => array:6 [ "tituloSerie" => "Pediatr Blood Cancer" "fecha" => "2011" "volumen" => "56" "paginaInicial" => "783" "paginaFinal" => "788" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21370411" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0110" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neurocognitive deficits in children with sickle cell disease are associated with the severity of anemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C.T. Hijmans" 1 => "M.A. Grootenhuis" 2 => "J. Oosterlaan" 3 => "H. Heijboer" 4 => "M. Peters" 5 => "K. Fijnvandraat" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/pbc.22892" "Revista" => array:6 [ "tituloSerie" => "Pediatr Blood Cancer" "fecha" => "2011" "volumen" => "57" "paginaInicial" => "297" "paginaFinal" => "302" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21671366" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0115" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available in: <a class="elsevierStyleInterRef" id="intr0010" href="http://www.uptodate.com/contents/diagnosis-of-sickle-cell-disorders">http://www.uptodate.com/contents/diagnosis-of-sickle-cell-disorders</a>" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis of sickle cell disorders. UpToDate" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E.P. Vichinsky" 1 => "D.H. Mahoney" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2016" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0120" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available in: <a class="elsevierStyleInterRef" id="intr0015" href="http://www.uptodate.com/contents/overview-of-the-clinical-manifestations-of-sickle-cell-disease">http://www.uptodate.com/contents/overview-of-the-clinical-manifestations-of-sickle-cell-disease</a>" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Overview of the clinical manifestations of sickle cell disease. UpToDate" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E.P. Vichinsky" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2016" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0125" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available in: <a class="elsevierStyleInterRef" id="intr0020" href="http://www.uptodate.com/contents/sickle-cell-trait">http://www.uptodate.com/contents/sickle-cell-trait</a>" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sickle cell trait. UpToDate" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E.P. Vichinsky" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2016" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0130" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anemia falciforme" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. Cela" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Acta Pediatr Esp" "fecha" => "2008" "volumen" => "66" "paginaInicial" => "327" "paginaFinal" => "329" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0135" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[Spanish]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of systematic neonatal screening for sickle cell diseases in Madrid three years after its introduction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Cela de Julián" 1 => "E. Dulín Iñiguez" 2 => "M. Guerrero Soler" 3 => "M. Arranz Leirado" 4 => "P. Galarón García" 5 => "C. Beléndez Bieler" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "An Pediatr (Barc)" "fecha" => "2007" "volumen" => "66" "paginaInicial" => "382" "paginaFinal" => "386" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0140" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available in: <a class="elsevierStyleInterRef" id="intr0025" href="http://www.sehop.org/">www.SEHOP.org</a> [accessed 01.03.16]" "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Guía de práctica clínica sobre enfermedad de células falciformes pediátrica. Sociedad Española de Hematología y Oncología Pediátricas (SEHOP)" ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2010" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0145" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Brain imaging findings in pediatric patients with sickle cell disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.G. Steen" 1 => "T. Emudianughe" 2 => "G.M. Hankins" 3 => "L.W. Wynn" 4 => "W.C. Wang" 5 => "X. Xiong" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiol.2281020943" "Revista" => array:7 [ "tituloSerie" => "Radiology" "fecha" => "2003" "volumen" => "228" "paginaInicial" => "216" "paginaFinal" => "225" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12775848" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028208007140" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0150" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Silent cerebral infarcts in very young children with sickle cell anaemia are associated with a higher risk of stroke" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.I. Cancio" 1 => "K.J. Helton" 2 => "J.E. Schreiber" 3 => "M.P. Smeltzer" 4 => "G. Kang" 5 => "W.C. Wang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/bjh.13525" "Revista" => array:6 [ "tituloSerie" => "Br J Haematol" "fecha" => "2015" "volumen" => "171" "paginaInicial" => "120" "paginaFinal" => "129" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26058476" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0155" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predictors of academic achievement for school age children with sickle cell disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "K.E. Smith" 1 => "C.A. Patterson" 2 => "M.M. Szabo" 3 => "R.A. Tarazi" 4 => "L.P. Barakat" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/1754730X.2012.760919" "Revista" => array:6 [ "tituloSerie" => "Adv Sch Ment Health Promot" "fecha" => "2013" "volumen" => "6" "paginaInicial" => "5" "paginaFinal" => "20" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23459502" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0160" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of developmental delay and contributing factors among children with sickle cell disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.H. Drazen" 1 => "R. Abel" 2 => "M. Gabir" 3 => "G. Farmer" 4 => "A.A. King" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/pbc.25838" "Revista" => array:6 [ "tituloSerie" => "Pediatr Blood Cancer" "fecha" => "2016" "volumen" => "63" "paginaInicial" => "504" "paginaFinal" => "510" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26575319" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0165" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lessons from the stroke prevention trial in sickle cell anemia (STOP) study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.J. Adams" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Child Neurol" "fecha" => "2000" "volumen" => "15" "paginaInicial" => "344" "paginaFinal" => "349" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10830201" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0170" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The spectrum of brain MR abnormalities in sickle-cell disease: a report from the Cooperative Study of Sickle Cell Disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F.G. Moser" 1 => "S.T. Miller" 2 => "J.A. Bello" 3 => "C.H. Pegelow" 4 => "R.A. Zimmerman" 5 => "W.C. Wang" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Neuroradiol" "fecha" => "1996" "volumen" => "17" "paginaInicial" => "965" "paginaFinal" => "972" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8733975" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0175" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.T. Brouillette" 1 => "A. Morielli" 2 => "A. Leimanis" 3 => "K.A. Waters" 4 => "R. Luciano" 5 => "F.M. Ducharme" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "2000" "volumen" => "105" "paginaInicial" => "405" "paginaFinal" => "412" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10654964" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0180" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "PedsQL 4.0: Reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.W. Varni" 1 => "M. Seid" 2 => "P.S. Kurtin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med Care" "fecha" => "2001" "volumen" => "39" "paginaInicial" => "800" "paginaFinal" => "812" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11468499" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0185" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The PedsQL: measurement model for the pediatric quality of life inventory" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.W. Varni" 1 => "M. Seid" 2 => "C.A. Rode" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med Care" "fecha" => "1999" "volumen" => "37" "paginaInicial" => "126" "paginaFinal" => "139" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10024117" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0190" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Developmental function in toddlers with sickle cell anemia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F.D. Armstrong" 1 => "T.D. Elkin" 2 => "R.C. Brown" 3 => "P. Glass" 4 => "S. Rana" 5 => "J.F. Casella" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1542/peds.2012-0283" "Revista" => array:7 [ "tituloSerie" => "Pediatrics" "fecha" => "2013" "volumen" => "131" "paginaInicial" => "e406" "paginaFinal" => "e414" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23296434" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1472648314002466" "estado" => "S300" "issn" => "14726483" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014700000012/v1_201702040025/S2387020616307896/v1_201702040025/en/main.assets" "Apartado" => array:4 [ "identificador" => "43310" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014700000012/v1_201702040025/S2387020616307896/v1_201702040025/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616307896?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 March | 2 | 2 | 4 |
