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Validez discriminante y concordancia interobservador de 2 métodos de puntuación del test del reloj
Discriminant validity and inter-rater concordance of two scoring systems for the clock test
Teodoro del Sera,
Autor para correspondencia
teodorodelser@gmail.com

Autor para correspondencia.
, Belén Fradesa, Meritxell Valentí-Solera, María Ascensión Zea-Sevillaa, Elizabeth Valeriano-Lorenzob, Cristóbal Carnero-Pardob
a Unidad de Investigación Enfermedad de Alzheimer, Fundación CIEN. Instituto de Salud Carlos III, Madrid, España
b FIDYAN Neurocenter, Granada, España
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el Rapid Cognitive Screen<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">6</span></a> o el Addenbrooke Cognitive Examination III<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El TdR es breve&#44; simple&#44; y tiene buena fiabilidad interobservador<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">8&#44;9</span></a>&#46; Tambi&#233;n tiene buena sensibilidad para detectar el deterioro cognitivo &#40;DC&#41;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">10</span></a>&#44; ya que exige el concurso de m&#250;ltiples funciones cognitivas como atenci&#243;n&#44; comprensi&#243;n verbal&#44; memoria visual&#44; habilidad visoespacial&#44; programaci&#243;n motora&#44; abstracci&#243;n y respuesta inhibitoria<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; No est&#225; exento de inconvenientes&#44; especialmente en la evaluaci&#243;n de personas mayores&#44; analfabetas o escasamente escolarizadas&#44; ya que requiere unaa destreza grafomotora y est&#225; influido por la edad y el nivel educativo<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">8&#44;10&#8211;12</span></a>&#46; Tiene un buen rendimiento en la discriminaci&#243;n de los casos con demencia frente a controles&#44; pero mucho menor en la diferenciaci&#243;n de los casos con deterioro cognitivo ligero<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Se han propuesto numerosos m&#233;todos de puntuaci&#243;n para el TdR&#44; tanto cuantitativos como cualitativos<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">9&#44;14</span></a>&#44; sin que ninguno haya demostrado una utilidad sustancialmente mayor<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">9&#44;14&#8211;17</span></a>&#46; En Espa&#241;a se han validado y estandarizado 2 m&#233;todos de puntuaci&#243;n del TdR<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">2&#44;18&#8211;20</span></a>&#46; Ambos m&#233;todos son cuantitativos&#44; pero dan puntuaciones diferentes a los elementos del dibujo&#46; El primero de ellos<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">2&#44;18</span></a> utiliza unos criterios similares a los de Sunderland et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">21</span></a> y Rouleau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">22</span></a> y una escala de 0 a 10&#46; El segundo<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">19&#44;20</span></a>&#44; incorporado por Solomon en el test de los 7<span class="elsevierStyleHsp" style=""></span>min<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">5&#44;20</span></a>&#44; es una versi&#243;n abreviada del m&#233;todo de Freedmanet al&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">23</span></a> y utiliza una escala de 0 a 7&#46; No existe por el momento ninguna comparaci&#243;n de las cualidades psicom&#233;tricas de estos 2 m&#233;todos de correcci&#243;n que permita hacer una elecci&#243;n razonada entre ellos&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El objetivo de este estudio es evaluar un gran n&#250;mero de dibujos del TdR mediante estos 2 m&#233;todos de puntuaci&#243;n y calcular la validez discriminante y la concordancia interobservador de cada uno de ellos para comparar su utilidad cl&#237;nica en el cribado de deterioro cognitivo&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Metodolog&#237;a</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Participantes</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se han evaluado 2 colecciones de dibujos del TdR&#46; La primera de ellas incluye 116 dibujos obtenidos en 52 pacientes de la consulta de CC y 64 sujetos de un estudio cl&#237;nico caso control<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">24</span></a>&#41;&#46; Los sujetos fueron reclutados durante la evaluaci&#243;n cl&#237;nica de un posible DC&#46; La segunda incluye 2&#46;039 dibujos realizados por 579 voluntarios&#44; mayores de 69 a&#241;os&#44; reclutados en el proyecto Vallecas&#44; un estudio longitudinal de los determinantes del deterioro cognitivo en una cohorte de personas mayores<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">25</span></a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Procedimientos</span><p id="par0030" class="elsevierStylePara elsevierViewall">En todos los sujetos se realiz&#243; un examen cl&#237;nico y neurol&#243;gico&#44; y una extensa evaluaci&#243;n neuropsicol&#243;gica&#46; Tras ello fueron clasificados como sin deterioro cognitivo &#40;DC<span class="elsevierStyleSup">&#8722;</span>&#41; o con DC<span class="elsevierStyleSup">&#43;</span> seg&#250;n criterios est&#225;ndares de deterioro cognitivo ligero<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">26</span></a> y demencia<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">27</span></a> en los que la puntuaci&#243;n en el TdR no fue tenida en cuenta&#46; En la mayor&#237;a de los sujetos el DC era de probable origen neurodegenerativo&#44; pero no se han utilizado marcadores diagn&#243;sticos y no se ha considerado la etiolog&#237;a en el an&#225;lisis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Todos los individuos cuya informaci&#243;n cl&#237;nica y dibujos del reloj han sido analizados en este estudio hab&#237;an proporcionado el consentimiento informado para usar sus datos anonimizados en investigaci&#243;n cl&#237;nica&#46; El proyecto Vallecas fue aprobado por el Comit&#233; &#201;tico del Instituto de Salud Carlos III&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Dos profesionales expertos examinaron los dibujos de forma independiente y sin conocimiento del diagn&#243;stico&#46; La colecci&#243;n cl&#237;nica fue evaluada y puntuada por ambos evaluadores con los m&#233;todos de Sunderland y de Solomon&#59; la colecci&#243;n de voluntarios fue evaluada con un solo m&#233;todo por cada uno de ellos&#46; En todos los casos se siguieron los criterios de estandarizaci&#243;n en espa&#241;ol<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">18&#44;19</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">El m&#233;todo de Sunderland valora en una escala de 0 a 10 la esfera &#40;0 a 2 puntos&#41;&#44; la presencia y secuencia de los n&#250;meros &#40;0 a 4 puntos&#41; y la presencia y ubicaci&#243;n de las manecillas &#40;0 a 4 puntos&#41;&#46; El m&#233;todo de Solomon valora en una escala de 0 a 7 la presencia y disposici&#243;n de los n&#250;meros &#40;0 a 3 puntos&#41; y de las manecillas &#40;0 a 4 puntos&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables</span><p id="par0050" class="elsevierStylePara elsevierViewall">Se han recogido para este estudio las variables demogr&#225;ficas edad&#44; sexo y nivel educativo &#40;&#60;<span class="elsevierStyleHsp" style=""></span>estudios primarios&#44; estudios primarios hasta los 10 a&#241;os y &#62;<span class="elsevierStyleHsp" style=""></span>estudios primarios&#41;&#44; as&#237; como las puntuaciones de cada dibujo obtenidas con cada uno de los 2 m&#233;todos&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lisis de datos</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se han comparado las variables demogr&#225;ficas y las puntuaciones de los sujetos con DC<span class="elsevierStyleSup">&#43;</span> y DC<span class="elsevierStyleSup">&#8722;</span> mediante la <span class="elsevierStyleItalic">t</span> de Student para las variables continuas y el &#967;<span class="elsevierStyleSup">2</span> para las variables categoriales&#46; Se ha estimado la relaci&#243;n entre las puntuaciones obtenidas en el TdR con los 2 m&#233;todos mediante el estad&#237;stico <span class="elsevierStyleItalic">r</span> de Pearson&#46; La relaci&#243;n de las variables demogr&#225;ficas con las puntuaciones en el TdR se ha examinado mediante an&#225;lisis de regresi&#243;n lineal m&#250;ltiple&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">La validez discriminante de cada uno de los m&#233;todos de puntuaci&#243;n del TdR se ha calculado mediante el &#225;rea bajo la curva ROC &#40;aROC&#41;&#46; La comparaci&#243;n entre las curvas se ha realizado por el m&#233;todo de Hanley y McNeil<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">28</span></a>&#46; En ambas muestras se han calculado adem&#225;s&#44; la sensibilidad&#44; la especificidad&#44; el cociente de probabilidad positivo y el porcentaje de clasificaciones correctas&#46; Para estos c&#225;lculos se han utilizado los puntos de corte habitualmente aceptados en la cl&#237;nica&#58; &#8804;<span class="elsevierStyleHsp" style=""></span>8 en el m&#233;todo Sunderland y &#8804;<span class="elsevierStyleHsp" style=""></span>5 en el m&#233;todo Solomon&#44; pero se han explorado tambi&#233;n otros puntos de corte&#46; La fiabilidad interobservador se ha analizado mediante los coeficientes de correlaci&#243;n intraclase &#40;CCI&#41; y el coeficiente <span class="elsevierStyleItalic">kappa</span> en los 116 casos de la muestra cl&#237;nica que fueron valorados por los 2 evaluadores&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Los c&#225;lculos se han llevado a cabo con el programa SPSS&#174; 19<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">29</span></a>&#59; en los resultados se ha considerado un error alfa del 5&#37; bilateral o un intervalo de confianza del 95&#37;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><p id="par0070" class="elsevierStylePara elsevierViewall">La mayor&#237;a de los sujetos estudiados son mayores de 60 a&#241;os&#46; La edad es ligera y significativamente mayor en los sujetos con DC<span class="elsevierStyleSup">&#43;</span> solo en la muestra de voluntarios&#59; no hay diferencias por sexo&#44; y el nivel educativo de los sujetos con DC<span class="elsevierStyleSup">&#43;</span> es significativamente inferior en ambas muestras &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Los sujetos de la muestra cl&#237;nica fueron evaluados una sola vez y diagnosticados de DC<span class="elsevierStyleSup">&#8722;</span> &#40;42 casos&#41; o DC&#43; &#40;74 casos&#59; 38 deterioro cognitivo ligero y 36 demencia&#41;&#59; cada uno aporta un dibujo del reloj&#46; Los 579 voluntarios del proyecto Vallecas fueron evaluados en un n&#250;mero variable de ocasiones sucesivas con una periodicidad anual y aportan un total de 2&#46;039 dibujos del reloj&#59; el n&#250;mero de relojes correspondiente a cada evaluaci&#243;n anual se representa en la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#46; El n&#250;mero de sujetos con DC<span class="elsevierStyleSup">&#43;</span> y DC<span class="elsevierStyleSup">&#8722;</span> cambia en cada evaluaci&#243;n anual de seguimiento&#59; la muestra completa incluye 1&#46;808 relojes dibujados por sujetos con DC<span class="elsevierStyleSup">&#8722;</span> &#40;88&#44;7&#37;&#41; y 231 por sujetos con DC<span class="elsevierStyleSup">&#43;</span> &#40;11&#44;3&#37;&#59; 202 con deterioro cognitivo ligero y 29 con demencia&#41; en la evaluaci&#243;n correspondiente&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Las puntuaciones obtenidas con ambos m&#233;todos son significativamente inferiores en los dibujos de los sujetos con DC<span class="elsevierStyleSup">&#43;</span> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#44; y muestran entre s&#237; una alta y significativa correlaci&#243;n &#40;<span class="elsevierStyleItalic">r</span> de Pearson &#91;IC 95&#37;&#93;&#58; 0&#44;76 &#91;0&#44;74-0&#44;78&#93; en la muestra de voluntarios&#59; 0&#44;84 &#91;0&#44;78-0&#44;89&#93; en la muestra cl&#237;nica&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Hay una estrecha y significativa relaci&#243;n positiva de la educaci&#243;n y negativa del diagn&#243;stico de DC con las puntuaciones en el TdR en ambas muestras y m&#233;todos&#59; la edad y el sexo femenino solo muestran una relaci&#243;n negativa y significativa en la muestra de voluntarios que es m&#225;s numerosa &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">La validez discriminante de cada m&#233;todo se presenta mediante el aROC &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> y <a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#59; es mayor en ambas muestras con el m&#233;todo Solomon &#40;muestra cl&#237;nica&#58; 0&#44;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#59; muestra de voluntarios&#58; 0&#44;72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 en ambas muestras&#41; que con el m&#233;todo de Sunderland &#40;muestra cl&#237;nica&#58; 0&#44;73<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#59; muestra de voluntarios&#58; 0&#44;69<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 para ambas&#41;&#44; pero las diferencias entre &#225;reas &#40;muestra cl&#237;nica&#58; 0&#44;045 &#177; 0&#44;03&#59; <span class="elsevierStyleItalic">z</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;18&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;24&#44; muestra de voluntarios&#58; 0&#44;025 &#177; 0&#44;01&#59; <span class="elsevierStyleItalic">z</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;59&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;11&#41; no alcanzan significaci&#243;n estad&#237;stica&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a> presenta los principales par&#225;metros m&#233;tricos de ambos m&#233;todos con diferentes puntos de corte&#46; Los puntos de corte &#8804;<span class="elsevierStyleHsp" style=""></span>8 en el m&#233;todo Sunderland y &#8804;<span class="elsevierStyleHsp" style=""></span>5 en el m&#233;todo Solomon&#44; que son los que ofrecen mejores rendimientos diagn&#243;sticos en la muestra cl&#237;nica&#44; clasifican correctamente al 82&#37; de la muestra de voluntarios y al 71&#37; de la cl&#237;nica con el primero&#44; y al 84&#37; de la muestra de voluntarios y al 73&#37; de la cl&#237;nica con el segundo &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46; Los puntos de corte &#8804;<span class="elsevierStyleHsp" style=""></span>6 en el m&#233;todo Sunderland y &#8804;<span class="elsevierStyleHsp" style=""></span>4 en el m&#233;todo Solomon&#44; que son los que ofrecen mejores rendimientos diagn&#243;sticos en la muestra de voluntarios por la menor prevalencias de DC&#44; clasifican correctamente al 89&#37; de la muestra de voluntarios y al 63&#37; de la cl&#237;nica con el primero&#44; y al 89&#37; de la muestra de voluntarios y al 71&#37; de la cl&#237;nica con el segundo &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Las diferencias en las puntuaciones obtenidas por los dos evaluadores independientes en la muestra cl&#237;nica &#40;Solomon&#58; 0&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;8 y Sunderland&#58; &#8722;0&#44;04<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;1&#59; <span class="elsevierStyleItalic">t</span> para muestras apareadas 1&#44;3 y &#8722;0&#44;4&#44; respectivamente&#41; no son significativas&#46; Los &#237;ndices de fiabilidad interobservador son ligeramente mayores con el m&#233;todo Solomon &#40;CCI&#58; 0&#44;92 &#91;IC 95&#37;&#58; 0&#44;89-0&#44;95&#93;&#59; <span class="elsevierStyleItalic">kappa</span>&#58; 0&#44;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;03 &#91;IC 95&#37;&#58; 0&#44;71-0&#44;83&#93;&#41; que con el m&#233;todo Sunderland &#40;CCI&#58; 0&#44;90 &#91;IC 95&#37;&#58; 0&#44;86-0&#44;93&#93;&#59; <span class="elsevierStyleItalic">kappa</span>&#58; 0&#44;76<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;03 &#91;IC 95&#37;&#58; 0&#44;70-0&#44;83&#93;&#41;&#44; pero las diferencias no alcanzan significaci&#243;n estad&#237;stica&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discusi&#243;n</span><p id="par0105" class="elsevierStylePara elsevierViewall">Numerosos estudios han comparado varios m&#233;todos de puntuaci&#243;n del TdR en la detecci&#243;n del deterioro cognitivo y la mayor&#237;a concluyen que todos ellos recogen un n&#250;cleo com&#250;n de actividad cognitiva y tienen cualidades m&#233;tricas bastante similares<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">15&#44;17&#44;30&#8211;32</span></a>&#46; Por ello&#44; la decisi&#243;n sobre cu&#225;l utilizar depende de las preferencias y entrenamiento del evaluador o del tiempo y recursos disponibles&#46; Nuestros datos son concordantes con estos estudios comparativos&#44; pero al haber sido obtenidos en 2 muestras independientes&#44; numerosas&#44; y de procedencia y estructura diferentes&#44; son especialmente robustos&#46; Estos resultados indican que un m&#233;todo de puntuaci&#243;n m&#225;s complejo no proporciona mayor validez discriminante ni concordancia entre evaluadores&#44; aunque cabe esperar que aumente el tiempo y el coste de la evaluaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">15</span></a>&#46; En este estudio&#44; el m&#233;todo de Solomon&#44; que utiliza una escala m&#225;s simple&#44; ofrece una validez discriminante y una fiabilidad interobservador ligera pero no significativamente superiores al m&#233;todo de Sunderland&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">El rendimiento diagn&#243;stico del TdR puede mejorarse combinando m&#233;todos de puntuaci&#243;n cuantitativos y cualitativos<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">9&#44;33</span></a>&#44; o asoci&#225;ndolo a otras pruebas cognitivas<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">13&#44;34</span></a>&#46; Recientemente se est&#225;n aplicando nuevas tecnolog&#237;as&#44; como la utilizaci&#243;n de un l&#225;piz digital<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">35</span></a>&#44; o m&#233;todos de inteligencia artificial para mejorar la lectura y el tratamiento de los dibujos del TdR&#46; Estos m&#233;todos ofrecen buenos rendimientos diagn&#243;sticos y pueden representar el futuro de la evaluaci&#243;n de este y otros test de cribado cognitivo<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">36&#44;37</span></a>&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusiones</span><p id="par0115" class="elsevierStylePara elsevierViewall">La validez discriminante y la fiabilidad interobservador de estos 2 m&#233;todos de correcci&#243;n del TdR son similares&#46; Pero nuestros datos y otros recogidos de la literatura indican que&#44; para el cribado del deterioro cognitivo&#44; tanto en el entorno cl&#237;nico como poblacional&#44; un m&#233;todo de puntuaci&#243;n del TdR m&#225;s simple&#44; como el de Solomon&#44; ofrece los mismos resultados que el m&#225;s complejo de Sunderland&#44; por lo que parece m&#225;s pr&#225;ctico y razonable su uso<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">15&#8211;17</span></a>&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Autor&#237;as</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Dr&#46; Del Ser&#58; concepto y dise&#241;o del estudio&#44; interpretaci&#243;n de los datos&#44; supervisi&#243;n de los an&#225;lisis estad&#237;sticos y redacci&#243;n&#47;revisi&#243;n del art&#237;culo&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0130" class="elsevierStylePara elsevierViewall">B&#46; Frades&#58; adquisici&#243;n y evaluaci&#243;n de los dibujos&#44; interpretaci&#243;n de los datos y revisi&#243;n del art&#237;culo&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0135" class="elsevierStylePara elsevierViewall">M&#46; Valent&#237;&#44; M&#46;A&#46; Zea y E&#46;L&#46; Valeriano&#58; adquisici&#243;n de los dibujos&#44; interpretaci&#243;n de los datos y revisi&#243;n del art&#237;culo&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Dr&#46; Carnero-Pardo&#58; concepto y dise&#241;o del estudio&#44; realizaci&#243;n de los an&#225;lisis estad&#237;sticos&#44; interpretaci&#243;n de los datos y redacci&#243;n&#47;revisi&#243;n del art&#237;culo&#46;</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Financiaci&#243;n</span><p id="par0145" class="elsevierStylePara elsevierViewall">La presente investigaci&#243;n no ha recibido ayudas espec&#237;ficas provenientes de agencias del sector p&#250;blico&#44; sector comercial o entidades sin &#225;nimo de lucro&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicto de intereses</span><p id="par0150" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46; No tienen ning&#250;n empleo&#44; actividades de consultor&#237;a&#44; honorarios&#44; acciones&#44; patentes o becas relacionadas con el contenido de esta investigaci&#243;n&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">El Dr&#46; T&#46; del Ser dirigi&#243; hace a&#241;os la estandarizaci&#243;n para la poblaci&#243;n espa&#241;ola mayor de 70 a&#241;os de la versi&#243;n de Solomon del TdR&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Cinco de los autores son empleados de la Unidad de Investigaci&#243;n Enfermedad de Alzheimer de la Fundaci&#243;n CIEN&#44; que est&#225; financiada por el Instituto de Salud Carlos III y la Fundaci&#243;n Reina Sof&#237;a&#44; y han trabajado en el proyecto Vallecas de donde proceden gran parte de los datos de este estudio&#46; Los restantes datos proceden del centro FYDIAN regentado por el otro autor&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Comparar la validez discriminante y la fiabilidad interobservador de los 2 m&#233;todos de correcci&#243;n del test del reloj m&#225;s usados en Espa&#241;a&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Metodolog&#237;a</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se han evaluado 2 colecciones de dibujos del reloj obtenidos en un contexto cl&#237;nico &#40;116 casos&#59; 56&#44;8&#37; mujeres&#44; edad media 73&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;7 a&#241;os&#41; y en una cohorte de voluntarios &#40;2&#46;039 dibujos de 579 sujetos&#59; 59&#44;5&#37; mujeres&#44; edad media 78&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;8 a&#241;os&#41;&#46; Todos los sujetos fueron clasificados como sin deterioro cognitivo &#40;DC<span class="elsevierStyleSup">&#8722;</span>&#41; o con deterioro cognitivo &#40;DC<span class="elsevierStyleSup">&#43;</span>&#41; tras una extensa evaluaci&#243;n cl&#237;nica y neuropsicol&#243;gica&#46; Evaluadores expertos han valorado estos dibujos de forma independiente y sin conocimiento del diagn&#243;stico con los m&#233;todos de Sunderland y Solomon estandarizados en espa&#241;ol por Cacho &#40;rango&#58; 0 a 10&#41; y del Ser &#40;rango&#58; 0 a 7&#41;&#44; respectivamente&#46; Se ha calculado la validez discriminante de cada m&#233;todo mediante el &#225;rea bajo la curva ROC &#40;aROC&#41; en las 2 muestras&#44; y la fiabilidad interobservador mediante el coeficiente de correlaci&#243;n intraclase &#40;CCI&#41; y el coeficiente <span class="elsevierStyleItalic">kappa</span> en la muestra cl&#237;nica que fue valorada por los 2 evaluadores&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">No hay diferencias significativas en la validez discriminante de los m&#233;todos de Sunderland y Solomon en ninguna de las muestras &#40;cl&#237;nica&#58; aROC&#58; 0&#44;73 &#91;IC 95&#37;&#58; 0&#44;64-0&#44;81&#93; y 0&#44;77 &#91;IC 95&#37;&#58; 0&#44;69-0&#44;85&#93;&#44; respectivamente&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;19&#59; voluntarios&#58; aROC&#58; 0&#44;69 &#91;IC 95&#37;&#58; 0&#44;67-0&#44;71&#93; y 0&#44;72 &#91;IC 95&#37;&#58; 0&#44;69-0&#44;73&#93;&#44; respectivamente&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;08&#41;&#46; Los puntos de corte &#8804;<span class="elsevierStyleHsp" style=""></span>8 y &#8804;<span class="elsevierStyleHsp" style=""></span>5 clasifican correctamente al 71 y 73&#37; de la muestra cl&#237;nica y al 82 y 84&#37; de la muestra de voluntarios&#44; respectivamente&#46; Los 2 m&#233;todos tienen una buena concordancia en la muestra cl&#237;nica &#40;Sunderland&#58; CCI&#58; 0&#44;90 &#91;IC 95&#37;&#58; 0&#44;81-0&#44;93&#93;&#59; <span class="elsevierStyleItalic">kappa&#58;</span> 0&#44;76 &#91;IC 95&#37;&#58; 0&#44;70-0&#44;83&#93;&#59; Solomon&#58; 0&#44;92 &#91;IC 95&#37;&#58; 0&#44;88-0&#44;95&#93; y 0&#44;77 &#91;IC 95&#37;&#58; 0&#44;71-0&#44;83&#93;&#44; respectivamente&#41;&#44; algo mayor en el segundo&#44; aunque las diferencias no son significativas&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La validez discriminante y la fiabilidad interobservador de estos 2 m&#233;todos de correcci&#243;n del test del reloj son similares&#46; El m&#233;todo de Solomon&#44; m&#225;s breve y sencillo&#44; puede ser m&#225;s aconsejable en t&#233;rminos pragm&#225;ticos&#46;</p></span>"
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            "titulo" => "Metodolog&#237;a"
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            "titulo" => "Resultados"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To compare the discriminant validity and inter-rater reliability of the two scoring systems for the Clock test that are most used in Spain&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methodology</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Two collections of clock drawings obtained in a clinical context &#40;116 cases&#59; 56&#46;8&#37; women&#44; mean age 73&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;7 years&#41; and in a cohort of volunteers &#40;2039 drawings of 579 subjects&#59; 59&#46;5&#37; women&#44; mean age 78&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;8 years&#41; have been assessed&#46; All subjects were classified as cognitively normal &#40;CN&#41; or cognitively impaired &#40;CI&#41; after extensive clinical and neuropsychological evaluation&#46; Expert raters have evaluated these drawings independently and without knowledge of the diagnosis using the Sunderland and Solomon systems standardized in Spanish by Cacho &#40;range 0 to 10&#41; and del Ser &#40;range 0 to 7&#41; respectively&#46; The discriminant validity of each method was calculated in the two samples using the area under the ROC curve &#40;aROC&#41;&#44; and the inter-rater reliability was calculated in the clinical sample&#44; that was assessed by the two evaluators&#44; using the intraclass correlation coefficient &#40;ICC&#41; and the <span class="elsevierStyleItalic">kappa</span> coefficient&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">There are no significant differences in the discriminant validity of the Sunderland and Solomon systems in any of the samples &#40;clinical&#58; aROC 0&#46;73 &#91;CI95&#37;&#58; 0&#46;64-0&#46;81&#93; and 0&#46;77 &#91;CI95&#37;&#58; 0&#46;69-0&#46;85&#93; respectively&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;19&#59; volunteers&#58; aROC 0&#46;69 &#91;CI95&#37;&#58; 0&#46;67-0&#46;71&#93; and 0&#46;72 &#91;CI95&#37;&#58; 0&#46;69-0&#46;73&#93; respectively&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;08&#41;&#46; The cut-off points &#8804;8 and &#8804;5 correctly classify 71&#37; and 73&#37; of the clinical sample and 82&#37; and 84&#37; of the volunteer sample&#44; respectively&#46; Both systems have good agreement in the clinical sample &#40;Sunderland&#58; ICC 0&#46;90 &#91;CI95&#37;&#58; 0&#46;81-0&#46;93&#93;&#44; <span class="elsevierStyleItalic">kappa</span> 0&#46;76 &#91;CI95&#37;&#58; 0&#46;70-0&#46;83&#93;&#59; Solomon&#58; 0&#46;92 &#91;CI95&#37;&#58; 0&#46;88-0&#46;95&#93; and 0&#46;77 &#91;CI95&#37;&#58; 0&#46;71-0&#46;83&#93; respectively&#41;&#44; somewhat higher in the second&#44; although the differences are not significant&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The discriminant validity and inter-observer reliability of these two Clock Test correction systems are similar&#46; Solomon&#39;s method&#44; shorter and simpler&#44; may be more advisable in pragmatic terms&#46;</p></span>"
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            "titulo" => "Results"
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            "titulo" => "Conclusions"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">DC&#58; deterioro cognitivo&#59; No DC&#58; no deterioro cognitivo&#59; ns&#58; no significativo&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Los datos son&#58; media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desviaci&#243;n t&#237;pica &#91;rango&#93; para las variables cuantitativas y n&#46;&#176; de sujetos &#40;porcentaje&#41; para las cualitativas&#46; En la muestra de voluntarios las cifras est&#225;n referidas a los dibujos del reloj analizados&#46; Se han hecho las comparaciones estad&#237;sticas mediante la t de Student para las variables continuas y el &#967;<span class="elsevierStyleSup">2</span> para las variables categoriales&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Muestra de voluntarios<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;039&#41;</th><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Muestra cl&#237;nica<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>116&#41;</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t">78&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;7 &#91;69-89&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Sexo femenino&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">&#8722;0&#44;043<a class="elsevierStyleCrossRef" href="#tblfn0020">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#44;075<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#44;038&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">&#8722;0&#44;076&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">Nivel educativo&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;221<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;258<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;345<span class="elsevierStyleSup">&#42;&#42;&#42;</span>&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;258<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&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">Diagn&#243;stico de DC&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">&#8722;0&#44;297<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#44;334<a class="elsevierStyleCrossRef" href="#tblfn0020">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#44;361<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#44;312<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3658727.png"
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            0 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;</p>"
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            1 => array:3 [
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              "etiqueta" => "&#42;&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Relaciones entre las variables demogr&#225;ficas y las puntuaciones en el test del reloj</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Tabla 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">aROC<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>ee&#58; &#225;rea bajo la curva ROC<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>error est&#225;ndar&#59; IC 95&#37;&#58; intervalo de confianza del 95&#37;&#59; TdR&#58; test del reloj&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Muestra de voluntarios &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;039&#41;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Muestra cl&#237;nica &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>116&#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">aROC<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>ee&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">Valor de 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">aROC<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>ee<span class="elsevierStyleSup">a</span>&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;<span class="elsevierStyleSup">b</span>&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">Valor de 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">M&#233;todo Sunderland&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;69<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;02&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;67-0&#44;71&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;73<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;05&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;64-0&#44;81&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">M&#233;todo Solomon&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;72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;02&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;69-0&#44;73&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;04&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;69-0&#44;85&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">Diferencia entre &#225;reas&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;025<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#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="" 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;08&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;045<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;03&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3658724.png"
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Validez discriminante de los dos m&#233;todos de puntuaci&#243;n del TdR</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Tabla 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">CC&#58; clasificaciones correctas&#59; CP<span class="elsevierStyleSup">&#43;</span>&#58; cociente de probabilidad positivo&#59; E&#58; especificidad&#59; PdC&#58; punto de corte&#59; S&#58; sensibilidad&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\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">&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">PdC&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  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Muestra de voluntarios &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;039&#41;</th><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">Muestra cl&#237;nica &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>116&#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="" 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">S&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">E&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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">S&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" scope="col" style="border-bottom: 2px solid black">E&nbsp;\t\t\t\t\t\t\n
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