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Detección de enfermedad hepática avanzada incorporando el uso de la elastografía de transición en atención primaria
Screening for advanced liver disease incorporating the use of transitional elastography in primary care
Mar Noguerol Álvareza,
Autor para correspondencia
marnoguerol@gmail.com

Autor para correspondencia.
, Ma Paz Valer López Fandob, Carolina Torrijos Bravoa, Ma Carmen Gómez Ortiza, Belén Piqueras Alcoholb, Antonio Guardiola Arévalob, Gema De la Poza Gómezb, Zahara Pascual Garcíaa, Sandra Rey Rodrígueza, Raquel Iglesias Sigüenzaa, Esther Ledesma Estéveza, Susana Parra Romána, María Gómez Suáreza, Angela Pérez San Juana, Miriam Ruiz Romeroa, Laura Martínez Vegaa, Beatriz López Uriartec, Francisco Góngora Maldonadoc, Blanca Martín Porrasc, Pilar Serrano Gismeroc..., Elvira Rubio Benitod, Gloria Viñas Fernándezd, Ma José Rojas Giraldoe, Ana Ma Hernández Sáncheze, María Alonso Oviesf, Gema María Saiz Laderaf, Nuria Martín Peñag, Jesús Fernández Horcajuelog, Victoria Llinares Gómezh, José Francisco Sánchez Mateosh, Elena Polentinos Castroi, Ricardo Rodríguez Barrientosi, Manuel Carbajo Arizai, Greta Amat Baezai, Fernando Bermejo San JosébVer más
a Centro de Salud Universitario Cuzco, Fuenlabrada, Madrid, España
b Servicio de Aparato Digestivo, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
c Centro de Salud Humanes, Madrid, España
d Centro de Salud Francia, Fuenlabrada, Madrid, España
e Centro de Salud Parque Loranca, Fuenlabrada, Madrid, España
f Centro de Salud Panaderas, Fuenlabrada, Madrid, España
g Centro de Salud Alicante, Fuenlabrada, Madrid, España
h Centro de Salud El Naranjo, Fuenlabrada, Madrid, España
i Unidad de apoyo a la investigación de Atención Primaria, Madrid, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La cirrosis es una de las principales causas de muerte&#44; de a&#241;os de vida perdidos y de a&#241;os de vida ajustados por discapacidad en todo el mundo&#46; La cirrosis y el carcinoma hepatocelular &#40;CHC&#41; causan el 3&#44;5&#37; de todas las muertes en el mundo&#46; Las principales causas de cirrosis en los pa&#237;ses desarrollados son el alcohol y la esteatosis hep&#225;tica metab&#243;lica &#40;EHmet&#41;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En el caso de la enfermedad hep&#225;tica grasa no alcoh&#243;lica &#40;EHGNA&#41;&#44; actualmente renombrada como enfermedad esteat&#243;sica hep&#225;tica asociada a disfunci&#243;n metab&#243;lica &#40;MASLD&#41; por el reciente consenso internacional<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a>&#44; y como EHmet en nuestro pa&#237;s<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a>&#44; varios estudios europeos&#44; anglosajones y espa&#241;oles han analizado su alta carga de comorbilidad y utilizaci&#243;n de recursos sanitarios&#44; que aumenta a medida que avanza la enfermedad<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5&#8211;8</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La enfermedad hep&#225;tica cr&#243;nica suele cursar de forma asintom&#225;tica y raramente se diagnostica en estadios precoces&#46; Adem&#225;s&#44; la bioqu&#237;mica hep&#225;tica no permite detectar la fibrosis hep&#225;tica&#44; que es la que determina la morbimortalidad de estos pacientes&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En la EHmet es la fibrosis&#44; no otros hallazgos histol&#243;gicos&#44; la que mejor predice como factor independiente la mortalidad general a largo plazo&#44; el trasplante hep&#225;tico y los eventos relacionados con hepatopat&#237;a<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Los m&#233;todos no invasivos para evaluar la fibrosis hep&#225;tica son la elastograf&#237;a de transici&#243;n &#40;ET&#41; que mide la rigidez hep&#225;tica&#44; y los m&#233;todos s&#233;ricos&#44; que incluyen determinaciones anal&#237;ticas patentadas e indicadores bioqu&#237;micos de fibrosis estimados por calculadoras en base a par&#225;metros habituales&#59; siendo los m&#225;s utilizados estos &#250;ltimos y concretamente el NAFLD fibrosis <span class="elsevierStyleItalic">score</span> &#40;NFS&#41; y el FIB-4 &#40;fibrosis-4&#41;&#44; que permiten excluir la fibrosis avanzada en una alta proporci&#243;n de pacientes &#40;valores predictivos negativos &#62;<span class="elsevierStyleHsp" style=""></span>90&#37;&#41;&#44; permitiendo un uso m&#225;s selectivo de la ET&#46; Las gu&#237;as actuales recomiendan el uso de los &#237;ndices s&#233;ricos de fibrosis en la pr&#225;ctica cl&#237;nica en atenci&#243;n primaria &#40;AP&#41;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;11</span></a>&#46; Se ha demostrado que el uso secuencial de diferentes pruebas no invasivas&#44; en concreto &#237;ndices s&#233;ricos m&#225;s ET&#44; mejoran la precisi&#243;n diagn&#243;stica<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Una revisi&#243;n sistem&#225;tica sobre los estudios poblacionales en AP estima la prevalencia de fibrosis significativa con distintos puntos de corte de la ET&#44; siendo para una medici&#243;n de la rigidez hep&#225;tica de 8 kilopascales &#40;kPa&#41; del 5&#44;8-7&#44;5&#37; y para una de 9-9&#44;6<span class="elsevierStyleHsp" style=""></span>kPa&#44; del 2-3&#44;6&#37;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">En un estudio realizado en los centros de salud de varias &#225;reas de Barcelona a m&#225;s de 3&#46;000 pacientes&#44; estableciendo puntos de corte en 6&#44;8&#44; 8 y 9<span class="elsevierStyleHsp" style=""></span>kPa&#44; se estimaron prevalencias de fibrosis significativa del 9&#44;5&#44; 8 y 3&#44;6&#37;&#44; respectivamente<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En los &#250;ltimos a&#241;os&#44; todas las gu&#237;as y publicaciones sobre la detecci&#243;n de fibrosis y cirrosis&#44; y espec&#237;ficamente en la EHmet&#44; han recomendado el uso secuencial de los m&#233;todos no invasivos bioqu&#237;micos de fibrosis y la ET<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;11&#44;15&#8211;18</span></a>&#46; Si los valores del indicador s&#233;rico hacen sospechar fibrosis&#44; se recomienda realizar ET o un indicador s&#233;rico de fibrosis patentado&#46; El cribado de la fibrosis hep&#225;tica con ET en AP es una intervenci&#243;n rentable para las poblaciones europeas y asi&#225;ticas e incluso puede suponer un ahorro de costes<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Por todo esto iniciamos un proyecto en poblaci&#243;n seleccionada en AP&#44; en colaboraci&#243;n con el servicio de digestivo&#44; en los dos municipios de la zona sur de la Comunidad de Madrid de los que es referencia&#44; incorporando el uso de FIB-4 y ET realizada en AP&#44; y derivando a los pacientes con sospecha de fibrosis tras dicho estudio&#44; con base en un protocolo consensuado entre AP y hospitalaria&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">El objetivo general fue conocer la proporci&#243;n de pacientes con fibrosis hep&#225;tica en la poblaci&#243;n con factores de riesgo &#40;FR&#41; de enfermedad hep&#225;tica avanzada&#44; identificada entre los pacientes atendidos en los centros de salud del &#225;rea sanitaria por cualquier motivo de salud&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Los objetivos secundarios fueron evaluar la correlaci&#243;n entre el indicador s&#233;rico de fibrosis FIB-4 y la ET&#44; y la correlaci&#243;n interobservador entre la ET realizada en AP y en atenci&#243;n hospitalaria &#40;AH&#41;&#44; e identificar los FR asociados con la presencia de fibrosis en la poblaci&#243;n estudiada&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes y m&#233;todos</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se trata de un estudio observacional descriptivo transversal&#44; realizado durante nueve meses &#40;desde noviembre de 2021 hasta julio de 2022&#41;&#46; Se incluyeron pacientes mayores de 16 a&#241;os procedentes de los centros de salud de Fuenlabrada y Humanes con FR de enfermedad hep&#225;tica cr&#243;nica&#46; Se excluyeron los pacientes con enfermedad hep&#225;tica diagnosticada previamente&#44; en seguimiento y tratamiento en el servicio de digestivo&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Para poder estimar una prevalencia esperada de fibrosis en sujetos de riesgo de un 6&#37;&#44; con una precisi&#243;n de<span class="elsevierStyleHsp" style=""></span>&#177; 0&#44;03&#44; en una poblaci&#243;n finita de unos 1&#46;000 sujetos con un error tipo I inferior a 0&#44;05&#44; se deb&#237;an incluir 194 pacientes&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se estudiaron variables sociodemogr&#225;ficas &#40;sexo y edad&#41; y la presencia de FR&#58; alteraci&#243;n de las pruebas bioqu&#237;micas hep&#225;ticas&#44; s&#237;ndrome metab&#243;lico o alguno de sus componentes&#44; diabetes tipo 2&#44; obesidad&#44; consumo de alcohol de riesgo&#44; y esteatosis hep&#225;tica diagnosticada por ecograf&#237;a o <span class="elsevierStyleItalic">fatty liver index</span> &#40;FLI&#41;&#46; Se midieron los siguientes par&#225;metros cl&#237;nicos&#58; valor del FIB-4&#44; valor del par&#225;metro de atenuaci&#243;n controlada &#40;CAP&#41; en decibelios por metro&#44; valor de la medici&#243;n de la rigidez hep&#225;tica por ET de vibraci&#243;n controlada &#40;VCTE&#41; en kilopascales&#44; en AP&#44; y en AH en aquellos pacientes derivados seg&#250;n el protocolo consensuado&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">A los pacientes con la bioqu&#237;mica hep&#225;tica alterada se les hicieron los estudios correspondientes seg&#250;n la pr&#225;ctica cl&#237;nica habitual&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">El valor del FIB-4 fue calculado de forma autom&#225;tica por el laboratorio bajo petici&#243;n espec&#237;fica en el formulario de AP&#46; A aquellos pacientes con valores iguales o superiores a 1&#44;3 se les realiz&#243; ET en AP con determinaci&#243;n asociada del CAP para cuantificar la esteatosis hep&#225;tica<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">20&#44;21</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Se utiliz&#243; un dispositivo de VCTE&#44; con sondas M y XL&#44; que incorpora CAP&#44; modelo FibroScan&#174; 430 Mini en AP&#59; y un modelo FibroScan&#174; 402 en el hospital&#44; ambos fabricados por Echosens&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">El elast&#243;grafo de AP se localiz&#243; en un centro de salud donde se centralizaron todas las exploraciones de los pacientes incluidos en el estudio&#44; realizadas por un grupo de profesionales de medicina y enfermer&#237;a previamente instruidos en su uso&#46; En AP efectuaron la elastograf&#237;a todos los miembros del grupo investigador del centro de salud donde se ubic&#243; el FibroScan&#174;&#58; siete m&#233;dicos de familia y cinco enfermeras&#44; de acuerdo con las especificaciones t&#233;cnicas del fabricante&#44; y habiendo realizado previamente m&#225;s de 25 exploraciones&#46; En AH la realizaron los seis gastroenter&#243;logos del servicio que las hacen habitualmente&#44; todos expertos con m&#225;s de 300 procedimientos realizados&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Se sigui&#243; un algoritmo consensuado entre los centros de salud y el hospital para la derivaci&#243;n de los pacientes con riesgo de fibrosis seg&#250;n los resultados del FIB-4 y de la medici&#243;n de la rigidez hep&#225;tica por VCTE &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Se hizo un an&#225;lisis de las variables estudiadas describiendo las continuas por sus medidas de tendencia central y de dispersi&#243;n&#44; y las cualitativas por sus frecuencias&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Se estim&#243; el porcentaje de pacientes con fibrosis significativa&#44; considerando como valor de referencia el resultado de la ET en AH&#46; Se estudi&#243; la correlaci&#243;n entre los valores del FIB-4 y de la ET en AP y en AH&#44; y entre los resultados de la ET en AP y AH mediante el coeficiente de correlaci&#243;n intraclase&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">La presencia de fibrosis hep&#225;tica y su grado se ha estratificado seg&#250;n FIB-4 y seg&#250;n resultados de la ET&#44; clasificando como fibrosis descartada valores de FIB-4<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#44;3&#44; sospecha de fibrosis significativa con valores &#8805; 1&#44;3&#44; y de fibrosis avanzada valores &#8805; 2&#44;67&#46; Para los resultados de la medici&#243;n de la rigidez hep&#225;tica por ET se ha estratificado con los puntos de corte de &#8805; 8 y &#8805; 12<span class="elsevierStyleHsp" style=""></span>kPa &#40;seg&#250;n las recomendaciones de las gu&#237;as m&#225;s recientes&#41;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;16&#44;22&#8211;25</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Se estudi&#243; la asociaci&#243;n entre los FR y la presencia de fibrosis&#44; y se construy&#243; un modelo explicativo mediante una regresi&#243;n log&#237;stica predictiva&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0115" class="elsevierStylePara elsevierViewall">El diagrama de flujo de los pacientes estudiados se describe en la <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Se cribaron 676 pacientes con FR de enfermedad hep&#225;tica&#44; de ellos 334 presentaron FIB 4<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#44;3&#46; Ocho pacientes fueron excluidos del estudio por no haberse podido hacer la ET en AP&#44; por dificultades en la t&#233;cnica en siete de ellos y uno por no acudir a hacerla&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">De los 326 pacientes restantes&#44; 95 pacientes ten&#237;an valores de rigidez hep&#225;tica &#8805; 8<span class="elsevierStyleHsp" style=""></span>kPa en AP&#44; siendo derivados a AH&#46; Doce pacientes no acudieron a la cita de AH&#44; perdi&#233;ndose en el seguimiento&#46; La exploraci&#243;n fue factible en todos los casos&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">El 70&#44;9&#37; de los pacientes con sospecha de fibrosis significativa por los valores del FIB-4&#44; no se derivaron al hospital por tener una medida de la rigidez hep&#225;tica en AP &#60;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">De los 83 pacientes derivados que se hicieron ET en el servicio de digestivo&#44; 45 &#40;54&#44;2&#37;&#41; ten&#237;an valores &#8805; 8<span class="elsevierStyleHsp" style=""></span>kPa&#59; y en 25 de estos &#40;30&#37; del total&#41; la medida de la rigidez hep&#225;tica era &#8805; 12<span class="elsevierStyleHsp" style=""></span>kPa&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se describen las caracter&#237;sticas de la poblaci&#243;n total estudiada &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>326&#41; y por sexo &#40;el 57&#37; fueron hombres&#41; respecto a la presencia de los FR&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">La frecuencia de esteatosis hep&#225;tica medida por el CAP y definida por valores &#62;<span class="elsevierStyleHsp" style=""></span>275 decibelios por metro &#40;dB&#47;m&#41;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a>&#44; en nuestra poblaci&#243;n fue del 54&#37; &#40;IC 95&#37;&#58;48&#44;4-59&#44;5&#41;&#58; 176 de los pacientes estudiados&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se describen los pacientes en relaci&#243;n con el valor del FIB-4 y de la ET&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">La proporci&#243;n de los pacientes con una medida de la rigidez hep&#225;tica por ET &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa en AH&#44; el valor de referencia para determinar la presencia de fibrosis significativa fue del 13&#44;8&#37; &#40;45&#47;326&#41;&#44; y con una rigidez &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa o sospecha de fibrosis avanzada&#44; del 7&#44;6&#37; &#40;25&#47;326&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Se estudi&#243; la utilidad diagn&#243;stica del FIB-4 calculando sus valores predictivos&#44; cocientes de probabilidad&#44; sensibilidad y especificidad con relaci&#243;n a los valores de la ET en AP y en AH&#44; considerando esta como el valor de referencia &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Elevar el punto de corte del FIB-4 a &#8805;<span class="elsevierStyleHsp" style=""></span>2 en &#8805;<span class="elsevierStyleHsp" style=""></span>65 a&#241;os hubiera reducido de 213 a 63 el n&#250;mero de pacientes de esta edad que precisaron la realizaci&#243;n de ET en AP y se hubieran derivado menos pacientes&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Al comparar un valor del FIB-4 &#8805;<span class="elsevierStyleHsp" style=""></span>2&#44;67&#44; con sospecha de fibrosis avanzada&#44; con un valor de ET concordante en AP y AH de &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa&#44; que corresponder&#237;a tambi&#233;n a fibrosis avanzada&#44; los valores predictivos positivos ser&#237;an del 58&#37; y 57&#37;&#44; respectivamente&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">En cuanto a la correlaci&#243;n interobservador entre los resultados de la ET en AP y en AH&#44; el coeficiente de correlaci&#243;n intraclase para n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>83&#44; fue de 0&#44;433&#44; con un IC 95&#37; entre 0&#44;137 y 0&#44;630&#44; con p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#44; que corresponde con un grado de acuerdo moderado en la escala de Landis y Koch&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Al estudiar la rentabilidad de la ET en AP comparando con el valor final en AH&#44; para valores de rigidez hep&#225;tica &#8805;<span class="elsevierStyleHsp" style=""></span>8 kPa &#40;fibrosis significativa&#41;&#44; el 54&#37; de los que la presentan en la ET de AP&#44; la tendr&#225;n tambi&#233;n en AH&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">De los pacientes que en AP tengan valores de rigidez hep&#225;tica &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa &#40;fibrosis avanzada&#41;&#44; el 57&#37; de ellos los tendr&#225;n tambi&#233;n en la ET en AH&#44; siendo adem&#225;s tres veces m&#225;s probable que estos pacientes tengan fibrosis avanzada&#44; a que no la tengan&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">En cuanto a la asociaci&#243;n entre la presencia de fibrosis y los FR &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#44; en el an&#225;lisis bivariante se encuentra asociaci&#243;n para valores de ET &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa con la alteraci&#243;n de las pruebas hep&#225;ticas &#40;PH&#41; &#40;OR 2&#44;77 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; con la diabetes tipo 2 &#40;DT2&#41; &#40;OR 3&#44;3 y p&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; y con la presencia de esteatosis hep&#225;tica ecogr&#225;fica o valorada mediante FLI &#40;OR 2&#44;39 y p&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">Para valores de ET &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa&#44; se encuentra asociaci&#243;n con la alteraci&#243;n de PH &#40;OR 5&#44;38 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;006&#41;&#44; DT2 &#40;OR 2&#44;9 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#44; y obesidad &#40;OR 2&#44;79 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007&#41;&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">No existe asociaci&#243;n con el s&#237;ndrome metab&#243;lico ni con el consumo de alcohol&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">En el an&#225;lisis multivariante con una regresi&#243;n log&#237;stica&#44; para un valor de rigidez hep&#225;tica &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa en AP&#44; se encontraron como variables asociadas la alteraci&#243;n de las PH&#44; la DT2 y la presencia de esteatosis&#44; y para valores de ET &#8805; 12<span class="elsevierStyleHsp" style=""></span>kPa la elevaci&#243;n de las PH&#44; la DT2 y la obesidad&#46; Sin embargo&#44; al aplicar este modelo para los valores de la ET en AH&#44; para &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa no se asocia la DT2&#44; y para &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa solo la obesidad&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Un 30&#37; de los pacientes derivados fueron incluidos en programa de cribado de CHC&#44; detectando en uno de los pacientes un hepatocarcinoma en la ecograf&#237;a de cribado&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><p id="par0215" class="elsevierStylePara elsevierViewall">El creciente inter&#233;s por la MASLD&#47;EHmet en la comunidad cient&#237;fica se explica por el aumento continuado de su prevalencia&#44; y de sus complicaciones&#44; fundamentalmente el hepatocarcinoma<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">22&#8211;24</span></a>&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">El aumento de la prevalencia de la enfermedad hep&#225;tica avanzada y sus consecuencias en morbilidad y mortalidad&#44; as&#237; como en el uso y coste de los servicios sanitarios&#44; merece una especial atenci&#243;n por parte del sistema sanitario&#44; y potenciar el papel de la AP y el m&#233;dico de familia&#44; que debe tener acceso a las principales herramientas diagn&#243;sticas&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">La b&#250;squeda de enfermedad hep&#225;tica avanzada en AP se puede hacer al disponer de pruebas no invasivas que&#44; aplicadas en las poblaciones de riesgo&#44; pueden mejorar la detecci&#243;n precoz de fibrosis y la estratificaci&#243;n del riesgo&#44; as&#237; como la vinculaci&#243;n del paciente con la atenci&#243;n sanitaria m&#225;s apropiada&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">En nuestro estudio se aplica un algoritmo ya propuesto y validado en estudios previos&#44; sum&#225;ndose recientemente nuevas gu&#237;as cl&#237;nicas que lo avalan<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">25&#8211;28</span></a>&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">El uso de la ET en AP es algo que ya se realiza en otros pa&#237;ses como el Reino Unido&#44; donde desde 2020 hay un informe al respecto del <span class="elsevierStyleItalic">National Institute for Health and Care Excelence</span> &#40;NICE&#41;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a>&#46; Existe un amplio consenso entre sociedades cient&#237;ficas proponiendo el cribado de enfermedad hep&#225;tica en AP y otras especialidades m&#233;dicas que atienden a pacientes de grupos de riesgo&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">En nuestro pa&#237;s no hemos encontrado publicaciones sobre experiencias similares a la que se ha llevado a cabo en este estudio&#44; aplicando a la pr&#225;ctica cl&#237;nica diaria un protocolo que incorpore la determinaci&#243;n autom&#225;tica en el informe de laboratorio del FIB-4 a petici&#243;n del m&#233;dico de AP&#44; y disponiendo de ET en AP para una mejor selecci&#243;n de los pacientes que precisan ser derivados a AH&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">La proporci&#243;n final entre la poblaci&#243;n de riesgo testada con FIB-4 en nuestro estudio&#44; con sospecha de fibrosis significativa &#40;&#8805; 8<span class="elsevierStyleHsp" style=""></span>kPa&#41; y de fibrosis avanzada &#40;&#8805; 12<span class="elsevierStyleHsp" style=""></span>kPa&#41; fue del 13&#44;8&#37; y 7&#44;6&#37;&#44; respectivamente&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Una de las limitaciones de nuestro estudio es que no se puede calcular una prevalencia poblacional&#44; al no haberse realizado correctamente el registro de todos los pacientes a los que se hizo FIB-4 y se obtuvo un valor &#8804; 1&#44;3&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Las pruebas no invasivas en AP y AH fueron bien aceptadas por los pacientes incluidos en el estudio&#46; Un paciente en AP y 12 en AH &#40;12&#44;6&#37; de los derivados&#41; se perdieron en el seguimiento al no acudir a la realizaci&#243;n de ET&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Tanto el valor predictivo positivo como el negativo del FIB-4 en nuestro estudio result&#243; inferior a lo publicado en estudios previos&#44; esto puede ser debido a que se ha hecho el cribado en AP en vez de en AH&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">El bajo rendimiento general de la determinaci&#243;n del FIB-4 hace que se est&#233;n buscando alternativas con otros indicadores s&#233;ricos de fibrosis<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a>&#44; y que se haga necesario ajustar en &#8805; 65 a&#241;os a &#8805; 2 el punto de corte del FIB-4 para hacer ET&#44; como se recoge en varios consensos o gu&#237;as<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11&#44;18&#44;23</span></a>&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Consideramos relevantes como resultados del estudio que&#44; con el cribado de pacientes con FR para enfermedad hep&#225;tica&#44; incorporando en los centros de salud el FIB-4 y la ET&#44; solo se haya derivado un 29&#44;1&#37; de los pacientes testados&#59; y haber identificado en un periodo de nueve meses 25 pacientes con medida de la rigidez hep&#225;tica &#8805; 12 kPa&#44; que fueron incluidos en programa de cribado de CHC&#46; La concordancia interobservador moderada entre la ET en AP y AH se puede mejorar con la realizaci&#243;n de m&#225;s exploraciones&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">En cuanto a la falta de asociaci&#243;n de la presencia de fibrosis con el s&#237;ndrome metab&#243;lico tomado de manera laxa&#44; parece conveniente limitar las indicaciones para hacer FIB-4 a pacientes que cumplan los criterios diagn&#243;sticos de s&#237;ndrome metab&#243;lico estrictamente&#46; Se encontr&#243; una clara asociaci&#243;n&#44; tambi&#233;n en el an&#225;lisis multivariante con la alteraci&#243;n de las PH&#44; la DT2 y la presencia de esteatosis hep&#225;tica&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Como conclusiones se puede resaltar que nuestro estudio reafirma la viabilidad de las recomendaciones de las gu&#237;as para el cribado y detecci&#243;n precoz de fibrosis hep&#225;tica en las poblaciones de riesgo&#46; La aplicaci&#243;n en la pr&#225;ctica cl&#237;nica de un algoritmo diagn&#243;stico y de derivaci&#243;n ha sido bien aceptado por los pacientes y por los profesionales de AP y AH&#44; obteniendo buenos resultados en el diagn&#243;stico precoz de fibrosis&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">La realizaci&#243;n de FIB-4 y ET en AP permite disminuir el porcentaje de pacientes que se derivan a AH&#44; as&#237; como una mejor estratificaci&#243;n de los pacientes de riesgo&#44; siendo un aspecto importante para mejorar la rentabilidad del FIB-4&#44; su correcci&#243;n por edad del paciente&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">Dadas las limitaciones del estudio&#44; parece adecuado realizar estudios futuros de mayor calidad&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Limitaciones</span><p id="par0295" class="elsevierStylePara elsevierViewall">Una recogida deficiente de los datos de cribado con FIB-4 en los pacientes con FIB-4<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#44;3&#44; no permiten extraer conclusiones poblacionales sino solo de los pacientes con resultado de FIB-4 &#8805; 1&#44;3 en AP&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">El tiempo transcurrido entre las dos exploraciones con VCTE ha podido influir en la correlaci&#243;n de los valores de la rigidez hep&#225;tica entre AP y AH&#44; en parte por la modificaci&#243;n de los h&#225;bitos en los pacientes incluidos en el estudio&#46; El estudio de la correlaci&#243;n interobservador en la ET entre AP y AH tambi&#233;n puede estar sesgado al comparar solo los 83 valores derivados desde AP a AH&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicto de intereses</span><p id="par0305" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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    "fechaRecibido" => "2024-03-14"
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            0 => "Fibrosis hep&#225;tica"
            1 => "Indicadores s&#233;ricos de fibrosis"
            2 => "Elastograf&#237;a de transici&#243;n"
            3 => "Atencion primaria"
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            0 => "Liver fibrosis"
            1 => "Non-invasive fibrosis biomarkers"
            2 => "Transient elastography"
            3 => "Primary care"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Describir la proporci&#243;n de pacientes con fibrosis hep&#225;tica en poblaciones de riesgo en atenci&#243;n primaria &#40;AP&#41;&#46; Conocer la correlaci&#243;n entre el FIB-4 y la elastograf&#237;a de transici&#243;n &#40;ET&#41;&#44; correlaci&#243;n interobservador entre AP y atenci&#243;n hospitalaria &#40;AH&#41; en la ET&#44; y factores de riesgo &#40;FR&#41; asociados&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; descriptivo&#44; transversal en &#8805;<span class="elsevierStyleHsp" style=""></span>16 a&#241;os con FR para hepatopat&#237;a cr&#243;nica&#46; Se recogieron sexo y edad&#44; FR &#40;alteraci&#243;n pruebas hep&#225;ticas &#40;PH&#41;&#44; s&#237;ndrome metab&#243;lico&#44; diabetes&#44; obesidad&#44; consumo alcohol&#44; esteatosis hep&#225;tica&#41;&#44; y los valores del FIB-4&#44; par&#225;metro de atenuaci&#243;n controlada &#40;CAP&#41;&#44; ET en AP y en AH&#46; Seg&#250;n algoritmo consensuado&#44; se realiz&#243; ET de vibraci&#243;n controlada &#40;VCTE&#41; en AP a los pacientes con FIB-4<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#44;3&#44; deriv&#225;ndose a AH aquellos con medici&#243;n&#8805;<span class="elsevierStyleHsp" style=""></span>8 kilopascales &#40;kPa&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se estudiaron 326 pacientes&#46; El 71&#37; no se derivaron a AH&#44; por rigidez hep&#225;tica&#60;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa&#59; 83 de los 95 derivados hicieron ET en AH&#59; 45 &#40;54&#44;2&#37;&#41; ten&#237;an ET &#8805;<span class="elsevierStyleHsp" style=""></span>8&#44; siendo en 25 &#40;30&#37;&#41; &#8805;<span class="elsevierStyleHsp" style=""></span>12&#46; La proporci&#243;n de pacientes con rigidez &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa fue del 13&#44;8&#37; &#40;45&#47;326&#41; y &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa&#44; del 7&#44;6&#37; &#40;25&#47;326&#41;&#46; Los valores predictivos del FIB-4 fueron bajos&#46; El coeficiente de correlaci&#243;n interobservador entre la ET en AP y AH fue del 0&#44;433&#46; Variables asociadas con ET &#8805;<span class="elsevierStyleHsp" style=""></span>8 en AP&#58; alteraci&#243;n PH&#44; diabetes y esteatosis&#46; Con ET &#8805;<span class="elsevierStyleHsp" style=""></span>12&#58; alteraci&#243;n PH&#44; diabetes y obesidad&#46; Variables predictoras en an&#225;lisis multivariante&#58; alteraci&#243;n PH y obesidad&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El estudio apoya la realizaci&#243;n secuencial de &#237;ndices s&#233;ricos y ET como cribado de fibrosis en poblaci&#243;n de riesgo en AP&#44; que permite disminuir el porcentaje de pacientes que se derivan a AH&#44; y una mejor estratificaci&#243;n de los pacientes de riesgo&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To describe the proportion of patients with liver fibrosis in at-risk populations in primary care &#40;PC&#41;&#46; To know the agreement between FIB-4 and transitional elastography &#40;TE&#41;&#44; interobserver agreement between PC and hospital care &#40;HC&#41; in TE&#44; and associated risk Factors &#40;RF&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Observational&#44; descriptive&#44; cross-sectional study in &#8805;<span class="elsevierStyleHsp" style=""></span>16 years of age with RF for chronic liver disease&#46; Sex and age&#44; RF &#40;alteration of liver tests &#91;LT&#93;&#44; metabolic syndrome&#44; diabetes&#44; obesity&#44; alcohol consumption&#44; hepatic steatosis&#41;&#44; and FIB-4&#44; controlled attenuation parameter and TE in PC and in HC&#44; were collected&#46; According to a consensus algorithm&#44; vibration-controlled TE was performed in PC in patients with FIB-4<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#44;3&#44; and those with measurement &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa were referred to HC&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">326 patients were studied&#46; 71&#37; were not referred to HC&#44; due to liver stiffness &#60;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa&#46; 83 of the 95 derivations did TE in HC&#46; 45 &#40;54&#37;&#41; had TE &#8805;<span class="elsevierStyleHsp" style=""></span>8&#44; and 25 &#40;30&#37;&#41; &#8805;<span class="elsevierStyleHsp" style=""></span>12&#46; The proportion of patients with stiffness &#8805;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>kPa was 13&#44;8&#37; &#40;45&#47;326&#41; and &#8805;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>kPa&#44; 7&#44;6&#37; &#40;25&#47;326&#41;&#46; The predictive values of the FIB-4 were low&#46; The interobserver correlation coefficient between TE in PC and HC was 0&#44;433&#46; Variables associated with TE &#8805;<span class="elsevierStyleHsp" style=""></span>8 in PC&#58; LT alteration&#44; diabetes and steatosis&#46; With TE &#8805;<span class="elsevierStyleHsp" style=""></span>12&#58; LT alteration&#44; diabetes and obesity&#46; Predictor variables&#58; LT alteration and obesity&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The study supports the sequential performance of serum indices and TE as a screening for fibrosis in the at-risk population in PC&#44; which allows a reduction in the percentage of patients referred to AH&#44; and a better stratification of risk patients&#46;</p></span>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">67&#44;86 &#40;8&#44;57&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Edad mayores 65</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">103 &#40;73&#44;05&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96 &#40;29&#44;45&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">38 &#40;26&#44;95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">OBESIDAD</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">145 &#40;44&#44;48&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76 &#40;41&#44;08&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69 &#40;48&#44;94&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">181 &#40;55&#44;52&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">109 &#40;58&#44;92&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72 &#40;51&#44;06&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">ALCOHOL</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">100 &#40;30&#44;67&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">176 &#40;53&#44;99&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">103 &#40;55&#44;68&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73 &#40;51&#44;77&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "etiqueta" => "Tabla 2"
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            "detalle" => "Tabla "
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">AP&#58; atenci&#243;n primaria&#59; AH&#58; atenci&#243;n hospitalaria&#59; FIB-4&#58; fibrosis-4&#59; IC&#58; intervalo de confianza&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FIB-4 &#8805; 2&#44;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;6&#44;74&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">ELASTOGRAF&#205;A en AP &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">326&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>8-11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">ELASTOGRAF&#205;A en AH &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">83&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">FIB-4 &#8805; 1&#44;3 conET &#8805; 12 en AP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FIB-4 &#8805; 1&#44;3 conET &#8805; 8 en AH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43-65&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">30&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;770&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;47-5&#44;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#237;ndrome metab&#243;lico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;620&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;98-2&#44;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;057&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes tipo 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;310&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;99-5&#44;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obesidad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;540&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;97-2&#44;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;061&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alcohol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;360&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;82-2&#44;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;231&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Esteatosis hep&#225;tica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;390&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;45-3&#44;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3660808.png"
              ]
            ]
            1 => 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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">An&#225;lisis bivariante para fibrosis avanzada &#40;12 kPa&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Elevaci&#243;n pruebas hep&#225;ticas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;6-17&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#237;ndrome metab&#243;lico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;830&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;89-3&#44;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;095&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes tipo 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;940&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;51-5&#44;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obesidad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;790&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;31-5&#44;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alcohol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;800&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;38-1&#44;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;568&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Esteatosis hep&#225;tica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;760&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;88-3&#44;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;106&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3660810.png"
              ]
            ]
            2 => 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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="6" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AN&#193;LISIS MULTIVARIANTE&#58; Variables predictoras</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#40;-2LL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">R<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Para ET en AP 8</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alteraci&#243;n PH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;56-5&#44;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-176&#44;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes tipo 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3&#44;58&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;08-6&#44;14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Esteatosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes tipo 2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alteraci&#243;n PH&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad&nbsp;\t\t\t\t\t\t\n
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                            3 => "S&#46;M&#46; Francque"
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Información del artículo
ISSN: 02105705
Idioma original: Español
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