Editorial
Diagnosing streptococcal pharyngotonsillitis in children and adolescents: the limitations of the clinical features*
Saulo Duarte Passos
Faculdade de Medicina de Jundiaí (FMJ), Jundiaí, SP, Brazil
Read
2209
Timeswas read the article
584
Total PDF
1625
Total HTML
Share statistics
array:23 [ "pii" => "S2359348215300609" "issn" => "23593482" "doi" => "10.1016/S2359-3482(15)30060-9" "estado" => "S300" "fechaPublicacion" => "2014-12-01" "aid" => "30060" "copyright" => "Sociedade de Pediatria de São Paulo. Published by Elsevier Editora Ltda. All rights reserved.. All rights reserved" "copyrightAnyo" => "2014" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "edi" "cita" => "Rev Paul Ped. 2014;32:283-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 311 "formatos" => array:3 [ "EPUB" => 7 "HTML" => 222 "PDF" => 82 ] ] "itemSiguiente" => array:19 [ "pii" => "S2359348215300610" "issn" => "23593482" "doi" => "10.1016/S2359-3482(15)30061-0" "estado" => "S300" "fechaPublicacion" => "2014-12-01" "aid" => "30061" "copyright" => "Sociedade de Pediatria de São Paulo. Published by Elsevier Editora Ltda. All rights reserved." "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Paul Ped. 2014;32:285-91" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 139 "formatos" => array:3 [ "EPUB" => 8 "HTML" => 89 "PDF" => 42 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Diagnosis of streptococcal pharyngotonsillitis in children and adolescents: clinical picture limitations<a class="elsevierStyleCrossRef" href="#fn1"><span class="elsevierStyleSup">*</span></a>" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "285" "paginaFinal" => "291" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Diagnóstico da faringoamigdalite estreptocócica em crianças e adolescentes: limitações do quadro clínico" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Aurelino Rocha Barbosa, Cláudia Di Lorenzo Oliveira, Maria Jussara Fernandes Fontes, Laura Maria de Lima Bezário Facury Lasmar, Paulo Augusto Moreira Camargos" "autores" => array:5 [ 0 => array:3 [ "nombre" => "Aurelino Rocha" "apellidos" => "Barbosa" "sufijo" => "Júnior" ] 1 => array:2 [ "nombre" => "Cláudia" "apellidos" => "Di Lorenzo Oliveira" ] 2 => array:2 [ "nombre" => "Maria Jussara Fernandes" "apellidos" => "Fontes" ] 3 => array:2 [ "nombre" => "Laura Maria" "apellidos" => "de Lima Bezário Facury Lasmar" ] 4 => array:2 [ "nombre" => "Paulo Augusto" "apellidos" => "Moreira Camargos" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2359348215300610?idApp=UINPBA00004N" "url" => "/23593482/0000003200000004/v1_201507180038/S2359348215300610/v1_201507180038/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Diagnosing streptococcal pharyngotonsillitis in children and adolescents: the limitations of the clinical features<a class="elsevierStyleCrossRef" href="#fn1"><span class="elsevierStyleSup">*</span></a>" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "283" "paginaFinal" => "284" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Saulo Duarte Passos" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Saulo Duarte" "apellidos" => "Passos" "email" => array:1 [ 0 => "sauloduarte@uol.com.br" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Faculdade de Medicina de Jundiaí (FMJ), Jundiaí, SP, Brazil" "identificador" => "aff1" ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="para10" class="elsevierStylePara elsevierViewall">Barbosa Junior <span class="elsevierStyleItalic">et al</span>, address in this issue the experience of the group on a relevant matter in pediatric practice: the diagnosis of Streptococcal Pharyngotonsillitis (SPT). “Sore throat” symptoms, including pharyngitis, are common reasons for seeking medical assistance in primary care and emergency services,<a class="elsevierStyleCrossRef" href="#bib1"><span class="elsevierStyleSup">1</span></a> accounting for 12 million consultations a year in the United States in 2006, with a significant impact to the healthcare system.<a class="elsevierStyleCrossRef" href="#bib2"><span class="elsevierStyleSup">2</span></a> Although most cases of pharyngitis have viral etiology (50–80%), bacterial agents are implicated in approximately 5–30% of the cases.<a class="elsevierStyleCrossRefs" href="#bib3"><span class="elsevierStyleSup">3–5</span></a> In cases of bacterial pharyngitis, infections caused by <span class="elsevierStyleItalic">Streptococcus pyogenes</span> (SGA) are the most frequent. The importance of identifying and treating them with appropriate antibiotics, both in the choice of drug and the beginning and time of administration are essential, as they reduce clinical symptoms and transmission to close contacts.<a class="elsevierStyleCrossRef" href="#bib6"><span class="elsevierStyleSup">6</span></a></p><p id="para20" class="elsevierStylePara elsevierViewall">The concern with diagnostic accuracy is a long-standing fact. In 1961, Stillerman & Bernstein<a class="elsevierStyleCrossRef" href="#bib7"><span class="elsevierStyleSup">7</span></a> warned: “If you are comfortable selecting which patients with pharyngitis should receive 10 days of treatment with penicillin, you may not understand the situation.” This discomfort persists even today, as there is no clinical evidence that cases of bacterial pharyngitis are more serious than viral ones or that there are differences in duration in both cases. Given these several etiological possibilities, accurate clinical diagnosis becomes a challenge, efficiently met by the study authors. Some aspects should be emphasized. Different from other studies,<a class="elsevierStyleCrossRefs" href="#bib7"><span class="elsevierStyleSup">7,8</span></a> the exclusion criteria of patients due to previous antibiotic use was extended to up to 30 days for those who used Benzathine penicillin, for patients treated in emergency rooms and outpatient clinics.</p><p id="para30" class="elsevierStylePara elsevierViewall">The case definition used was laboratory-based and stringent, using the combination of the results of rapid antigen detection test and/or culture for SGA. Admission criteria were broad, including upper airway symptoms, which may have interfered with the lower positivity (23.4%) of laboratory tests for SPT detection,<a class="elsevierStyleCrossRefs" href="#bib9"><span class="elsevierStyleSup">9,10</span></a> when compared to other works in our country.<a class="elsevierStyleCrossRefs" href="#bib8"><span class="elsevierStyleSup">8,11</span></a> The exclusion of respiratory symptoms increases the pretest prevalence of streptococcal pharyngitis. The prevalence of SPT similar to the study was found in an international multicenter study that included Brazil, pointing out to the use of the rapid test for diagnosis.<a class="elsevierStyleCrossRef" href="#bib12"><span class="elsevierStyleSup">12</span></a></p><p id="para40" class="elsevierStylePara elsevierViewall">The clinical characteristics presented in this study showed increased sensitivity, with low specificity for the diagnosis of SPT by SGA. These criteria could delay antibiotic treatment aimed at eradication of streptococci from the oropharynx. Antibiotics can probably prevent complications, although these are rare.<a class="elsevierStyleCrossRef" href="#bib13"><span class="elsevierStyleSup">13</span></a></p><p id="para50" class="elsevierStylePara elsevierViewall">The introduction of the score system resulted in higher specificity and lower sensitivity of the clinical picture. The search for suitable clinical scores has been a concern to institute SGA control policies. In 1981, Centor et al.<a class="elsevierStyleCrossRef" href="#bib10"><span class="elsevierStyleSup">10</span></a> developed criteria to predict the likelihood of SGA presence in cultures of adult patients, but it became a tool for the assessment of SG absence. Other studies with children established clinical scores aiming at an empirical antibiotic therapy, with good results.<a class="elsevierStyleCrossRefs" href="#bib14"><span class="elsevierStyleSup">14,15</span></a></p><p id="para60" class="elsevierStylePara elsevierViewall">The clinical score is not used as a consensus, as some studies have shown that empiric treatment can lead to a significant amount of unnecessary antibiotic use<a class="elsevierStyleCrossRefs" href="#bib16"><span class="elsevierStyleSup">16,18</span></a> and others have shown that there is no advantage in using clinical scores alone on the association with the rapid test.<a class="elsevierStyleCrossRef" href="#bib19"><span class="elsevierStyleSup">19</span></a> Other studies have associated other tests, such as leukogram and C-reactive protein, to clinical criteria, with improved specificity.<a class="elsevierStyleCrossRef" href="#bib1"><span class="elsevierStyleSup">1</span></a> This subject offers a wide opportunity for studies to better understand and diagnose SGA, aiming to optimize the prescription and reduce the resistance of antibiotic agents.</p><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">Conflicts of interest</span><p id="para70" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "cesec10" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "<span class="elsevierStyleSectionTitle" id="cestitle30">Uncited Reference</span>" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">Institution: Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brazil.</p>" "identificador" => "fn1" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis of acute tonsillopharyngitis in primary care: a new approach for low-resource settings" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => """ Z Alper \n \t\t\t\t\t\t\t\t """ 1 => """ Y Uncu \n \t\t\t\t\t\t\t\t """ 2 => """ H Akalin \n \t\t\t\t\t\t\t\t """ 3 => """ I Ercan \n \t\t\t\t\t\t\t\t """ 4 => """ M Sinirtas \n \t\t\t\t\t\t\t\t """ 5 => """ NG Bilgel \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1179/1973947813Y.0000000071" "Revista" => array:6 [ "tituloSerie" => "J Chemother" "fecha" => "2013" "volumen" => "25" "paginaInicial" => "148" "paginaFinal" => "155" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23783139" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ambulatory medical care utilization estimates for 2007" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ SM Schappert \n \t\t\t\t\t\t\t\t """ 1 => """ EA Rechtsteiner \n \t\t\t\t\t\t\t\t """ 2 => """ Division of Health Care Statistics \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Vital Health Stat" "fecha" => "2007" "volumen" => "13" "paginaInicial" => "1" "paginaFinal" => "38" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute pharyngitis: etiology and diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => """ AL Bisno \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "1996" "volumen" => "97" "paginaInicial" => "949" "paginaFinal" => "954" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8637780" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => """ Scottish Intercollegiate Guidelines Network \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "titulo" => "Management of sore throat and indications for tonsillectomy" "fecha" => "2010" "editorial" => "SIGN" "editorialLocalizacion" => "Edinburgh" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The rational clinical examination. Does this patient have strep throat?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => """ MH Ebell \n \t\t\t\t\t\t\t\t """ 1 => """ MA Smith \n \t\t\t\t\t\t\t\t """ 2 => """ HC Barry \n \t\t\t\t\t\t\t\t """ 3 => """ K Ives \n \t\t\t\t\t\t\t\t """ 4 => """ M Carey \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2000" "volumen" => "284" "paginaInicial" => "2912" "paginaFinal" => "2918" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11147989" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical course of suspected viral sore throat in young adults: cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => """ M Lindbaek \n \t\t\t\t\t\t\t\t """ 1 => """ N Francis \n \t\t\t\t\t\t\t\t """ 2 => """ R Cannings-John \n \t\t\t\t\t\t\t\t """ 3 => """ CC Butler \n \t\t\t\t\t\t\t\t """ 4 => """ P Hjortdahl \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/02813430600638227" "Revista" => array:7 [ "tituloSerie" => "Scand J Prim Health Care" "fecha" => "2006" "volumen" => "24" "paginaInicial" => "93" "paginaFinal" => "97" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16690557" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673607604565" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Streptococcal Pharyngitis: Evaluation of clinical syndromes in diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ M Stillerman \n \t\t\t\t\t\t\t\t """ 1 => """ S Bernstein \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Dis Child" "fecha" => "1961" "volumen" => "101" "paginaInicial" => "476" "paginaFinal" => "489" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of the rapid antigen detection test in diagnosis and treatment od acute pharyngotonsillits in a Pediatric emergency room" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ DM Cardoso \n \t\t\t\t\t\t\t\t """ 1 => """ AE Gilio \n \t\t\t\t\t\t\t\t """ 2 => """ SH Hsin \n \t\t\t\t\t\t\t\t """ 3 => """ BM Machado \n \t\t\t\t\t\t\t\t """ 4 => """ M Paulis \n \t\t\t\t\t\t\t\t """ 5 => """ JP Lotufo \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Paul Pediatr" "fecha" => "2013" "volumen" => "31" "paginaInicial" => "4" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23703037" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluating the american academy of pediatrics diagnostic standard for streptococcus pyogenes pharyngitis: backup culture versus repeat rapid antigen testing" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ KE Gieseker \n \t\t\t\t\t\t\t\t """ 1 => """ MH Roe \n \t\t\t\t\t\t\t\t """ 2 => """ T MacKenzie \n \t\t\t\t\t\t\t\t """ 3 => """ JK Todd \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "2003" "volumen" => "111" "paginaInicial" => "e666" "paginaFinal" => "e670" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12777583" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The diagnosis of strep throat in adults in the emergency room" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => """ RM Centor \n \t\t\t\t\t\t\t\t """ 1 => """ JM Witherspoon \n \t\t\t\t\t\t\t\t """ 2 => """ HP Dalton \n \t\t\t\t\t\t\t\t """ 3 => """ CE Brody \n \t\t\t\t\t\t\t\t """ 4 => """ K Link \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med Decis Making" "fecha" => "1981" "volumen" => "1" "paginaInicial" => "239" "paginaFinal" => "246" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6763125" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparative analysis of clinical and laboratory methods for diagnosing streptococcal sore throat" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ AG dos Santos \n \t\t\t\t\t\t\t\t """ 1 => """ EN Berezin \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Pediatr (Rio J)" "fecha" => "2005" "volumen" => "81" "paginaInicial" => "23" "paginaFinal" => "28" "itemHostRev" => array:3 [ "pii" => "S001502821002978X" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The utility of rapid antigen detection testing for the diagnosis of streptococcal pharyngitis in low-resource settings" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ AW Rimoin \n \t\t\t\t\t\t\t\t """ 1 => """ CL Walker \n \t\t\t\t\t\t\t\t """ 2 => """ HS Hamza \n \t\t\t\t\t\t\t\t """ 3 => """ N Elminawi \n \t\t\t\t\t\t\t\t """ 4 => """ HA Ghafar \n \t\t\t\t\t\t\t\t """ 5 => """ A Vince \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijid.2010.02.2269" "Revista" => array:6 [ "tituloSerie" => "Int J Infect Dis" "fecha" => "2010" "volumen" => "14" "paginaInicial" => "e1048" "paginaFinal" => "e1053" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21036645" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antibiotics for sore throat" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ CB Del Mar \n \t\t\t\t\t\t\t\t """ 1 => """ PP Glasziou \n \t\t\t\t\t\t\t\t """ 2 => """ AB Spinks \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD003881.pub3" "Revista" => array:5 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2004" "volumen" => "2" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22336797" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S001502821102824X" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pragmatic scoring system for pharyngitis in low-resource settings" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ L Joachim \n \t\t\t\t\t\t\t\t """ 1 => """ D Campos Jr \n \t\t\t\t\t\t\t\t """ 2 => """ PR Smeesters \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1542/peds.2010-0569" "Revista" => array:7 [ "tituloSerie" => "Pediatrics" "fecha" => "2010" "volumen" => "126" "paginaInicial" => "e608" "paginaFinal" => "e614" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20696724" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028207000428" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Centor criteria in children in a paediatric emergency department: for what it is worth" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => """ I Roggen \n \t\t\t\t\t\t\t\t """ 1 => """ G van Berlaer \n \t\t\t\t\t\t\t\t """ 2 => """ F Gordts \n \t\t\t\t\t\t\t\t """ 3 => """ D Pierard \n \t\t\t\t\t\t\t\t """ 4 => """ I Hubloue \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bmjopen-2013-002712" "Revista" => array:6 [ "tituloSerie" => "BMJ Open" "fecha" => "2013" "volumen" => "3" "paginaInicial" => "e002712" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23613571" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028214004695" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Empirical validation of guidelines for the management of pharyngitis in children and adults" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => """ WJ McIsaac \n \t\t\t\t\t\t\t\t """ 1 => """ JD Kellner \n \t\t\t\t\t\t\t\t """ 2 => """ P Aufricht \n \t\t\t\t\t\t\t\t """ 3 => """ A Vanjaka \n \t\t\t\t\t\t\t\t """ 4 => """ DE Low \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.291.13.1587" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2004" "volumen" => "291" "paginaInicial" => "1587" "paginaFinal" => "1595" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15069046" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The validity of a sore throat score in family practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ WJ McIsaac \n \t\t\t\t\t\t\t\t """ 1 => """ V Goel \n \t\t\t\t\t\t\t\t """ 2 => """ T To \n \t\t\t\t\t\t\t\t """ 3 => """ DE Low \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "CMAJ" "fecha" => "2000" "volumen" => "163" "paginaInicial" => "811" "paginaFinal" => "815" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11033707" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => """ P Little \n \t\t\t\t\t\t\t\t """ 1 => """ FD Hobbs \n \t\t\t\t\t\t\t\t """ 2 => """ M Moore \n \t\t\t\t\t\t\t\t """ 3 => """ D Mant \n \t\t\t\t\t\t\t\t """ 4 => """ I Williamson \n \t\t\t\t\t\t\t\t """ 5 => """ C McNulty \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "BMJ" "fecha" => "2013" "volumen" => "347" "paginaInicial" => "f5806" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24114306" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028208048188" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] ] ] ] ] "lecturaRecomendada" => array:1 [ 0 => array:3 [ "vista" => "all" "titulo" => "<span class="elsevierStyleSectionTitle" id="cestitle30">Uncited Reference</span>" "seccion" => array:1 [ 0 => array:2 [ "vista" => "all" "bibliografiaReferencia" => array:1 [ 0 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis of strep throat in adults: are clinical criteria really good enough?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ AL Bisno \n \t\t\t\t\t\t\t\t """ 1 => """ GS Peter \n \t\t\t\t\t\t\t\t """ 2 => """ EL Kaplan \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/342056" "Revista" => array:7 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2002" "volumen" => "35" "paginaInicial" => "126" "paginaFinal" => "129" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12087517" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S001502820603247X" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23593482/0000003200000004/v1_201507180038/S2359348215300609/v1_201507180038/en/main.assets" "Apartado" => array:4 [ "identificador" => "42247" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorial" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23593482/0000003200000004/v1_201507180038/S2359348215300609/v1_201507180038/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2359348215300609?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 3 | 7 | 10 |
| 2024 September | 30 | 20 | 50 |
| 2024 August | 13 | 3 | 16 |
| 2024 July | 8 | 8 | 16 |
| 2024 June | 6 | 7 | 13 |
| 2024 May | 9 | 12 | 21 |
| 2024 April | 15 | 12 | 27 |
| 2024 March | 14 | 5 | 19 |
| 2024 February | 6 | 6 | 12 |
| 2024 January | 6 | 5 | 11 |
| 2023 December | 5 | 19 | 24 |
| 2023 November | 13 | 7 | 20 |
| 2023 October | 8 | 0 | 8 |
| 2023 September | 15 | 6 | 21 |
| 2023 August | 7 | 5 | 12 |
| 2023 July | 6 | 3 | 9 |
| 2023 June | 25 | 0 | 25 |
| 2023 May | 40 | 15 | 55 |
| 2023 April | 32 | 3 | 35 |
| 2023 March | 32 | 9 | 41 |
| 2023 February | 27 | 3 | 30 |
| 2023 January | 14 | 4 | 18 |
| 2022 December | 10 | 6 | 16 |
| 2022 November | 10 | 5 | 15 |
| 2022 October | 6 | 4 | 10 |
| 2022 September | 13 | 8 | 21 |
| 2022 August | 17 | 14 | 31 |
| 2022 July | 14 | 9 | 23 |
| 2022 June | 12 | 11 | 23 |
| 2022 May | 16 | 11 | 27 |
| 2022 April | 23 | 11 | 34 |
| 2022 March | 42 | 10 | 52 |
| 2022 February | 49 | 9 | 58 |
| 2022 January | 61 | 10 | 71 |
| 2021 December | 53 | 8 | 61 |
| 2021 November | 41 | 11 | 52 |
| 2021 October | 49 | 13 | 62 |
| 2021 September | 23 | 15 | 38 |
| 2021 August | 29 | 6 | 35 |
| 2021 July | 48 | 8 | 56 |
| 2021 June | 30 | 10 | 40 |
| 2021 May | 30 | 10 | 40 |
| 2021 April | 83 | 21 | 104 |
| 2021 March | 64 | 18 | 82 |
| 2021 February | 37 | 26 | 63 |
| 2021 January | 47 | 13 | 60 |
| 2020 December | 48 | 10 | 58 |
| 2020 November | 40 | 9 | 49 |
| 2020 October | 29 | 6 | 35 |
| 2020 September | 14 | 9 | 23 |
| 2020 August | 13 | 11 | 24 |
| 2020 July | 29 | 8 | 37 |
| 2020 June | 11 | 5 | 16 |
| 2020 May | 15 | 6 | 21 |
| 2020 April | 26 | 4 | 30 |
| 2020 March | 21 | 7 | 28 |
| 2020 February | 25 | 3 | 28 |
| 2020 January | 18 | 4 | 22 |
| 2019 December | 25 | 4 | 29 |
| 2019 November | 35 | 8 | 43 |
| 2019 October | 23 | 6 | 29 |
| 2019 September | 29 | 6 | 35 |
| 2019 August | 10 | 2 | 12 |
| 2019 July | 4 | 7 | 11 |
| 2019 June | 5 | 2 | 7 |
| 2019 May | 16 | 11 | 27 |
| 2019 April | 1 | 0 | 1 |
| 2018 September | 1 | 0 | 1 |
| 2017 February | 0 | 1 | 1 |
| 2017 January | 17 | 9 | 26 |
| 2016 December | 8 | 8 | 16 |
| 2016 November | 2 | 2 | 4 |
| 2016 October | 2 | 6 | 8 |
| 2016 September | 6 | 2 | 8 |
| 2016 August | 5 | 1 | 6 |
| 2016 July | 6 | 1 | 7 |
Show all
