Acute Q fever and the risk of developing endocarditis

array:23 ["pii" => "S2254887415000387" "issn" => "22548874" "doi" => "10.1016/j.rceng.2015.01.003" "estado" => "S300" "fechaPublicacion" => "2015-06-01" "aid" => "1112" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "copyrightAnyo" => "2015" "documento" => "article" "subdocumento" => "sco" "cita" => "Rev Clin Esp. 2015;215:265-71" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 78 "formatos" => array:2 [ "HTML" => 75 "PDF" => 3 ] ] "Traduccion" => array:1 [ "es" => array:18 [ "pii" => "S0014256515000521" "issn" => "00142565" "doi" => "10.1016/j.rce.2015.01.011" "estado" => "S300" "fechaPublicacion" => "2015-06-01" "aid" => "1112" "copyright" => "Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "subdocumento" => "sco" "cita" => "Rev Clin Esp. 2015;215:265-71" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 666 "formatos" => array:2 [ "HTML" => 358 "PDF" => 308 ] ] "es" => array:12 [ "idiomaDefecto" => true "cabecera" => "ORIGINAL BREVE" "titulo" => "Fiebre Q aguda: riesgo de desarrollo de endocarditis" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "265" "paginaFinal" => "271" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Acute Q fever and the risk of developing endocarditis" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Martín-Aspas, C. Collado-Pérez, L. Vela-Manzano, C. Fernández-Gutiérrez del Álamo, I. Tinoco-Racero, J.A. Girón-González" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Martín-Aspas" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Collado-Pérez" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Vela-Manzano" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Fernández-Gutiérrez del Álamo" ] 4 => array:2 [ "nombre" => "I." "apellidos" => "Tinoco-Racero" ] 5 => array:2 [ "nombre" => "J.A." "apellidos" => "Girón-González" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2254887415000387" "doi" => "10.1016/j.rceng.2015.01.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887415000387?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256515000521?idApp=WRCEE" "url" => "/00142565/0000021500000005/v1_201506010559/S0014256515000521/v1_201506010559/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2254887415000272" "issn" => "22548874" "doi" => "10.1016/j.rceng.2015.03.001" "estado" => "S300" "fechaPublicacion" => "2015-06-01" "aid" => "1100" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "simple-article" "subdocumento" => "crp" "cita" => "Rev Clin Esp. 2015;215:276-84" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 121 "formatos" => array:2 [ "HTML" => 119 "PDF" => 2 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Clinical up-date" "titulo" => "Pernicious anemia. From past to present" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "276" "paginaFinal" => "284" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anemia perniciosa. Del pasado al presente" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2181 "Ancho" => 3250 "Tamanyo" => 602672 ] ] "descripcion" => array:1 [ "en" => "Pathophysiology of vitamin B12 absorption and deficiency." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Rodríguez de Santiago, C. Ferre Aracil, A. García García de Paredes, V.F. Moreira Vicente" "autores" => array:4 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Rodríguez de Santiago" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Ferre Aracil" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "García García de Paredes" ] 3 => array:2 [ "nombre" => "V.F." "apellidos" => "Moreira Vicente" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S001425651500003X" "doi" => "10.1016/j.rce.2014.12.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S001425651500003X?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887415000272?idApp=WRCEE" "url" => "/22548874/0000021500000005/v1_201506010556/S2254887415000272/v1_201506010556/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2254887415000090" "issn" => "22548874" "doi" => "10.1016/j.rceng.2015.01.001" "estado" => "S300" "fechaPublicacion" => "2015-06-01" "aid" => "1073" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2015;215:258-64" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 63 "formatos" => array:2 [ "HTML" => 61 "PDF" => 2 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Has the time come to search for the Wells score 4.0?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "258" "paginaFinal" => "264" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Ha llegado el momento de buscar la escala de Wells 4.0?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Rosa-Jiménez, A. Rosa-Jiménez, A. Lozano-Rodríguez, P. Martín-Moreno, M.D. Hinojosa-Martínez, Á.M. Montijano-Cabrera" "autores" => array:6 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Rosa-Jiménez" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Rosa-Jiménez" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Lozano-Rodríguez" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Martín-Moreno" ] 4 => array:2 [ "nombre" => "M.D." "apellidos" => "Hinojosa-Martínez" ] 5 => array:2 [ "nombre" => "Á.M." "apellidos" => "Montijano-Cabrera" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256514004330" "doi" => "10.1016/j.rce.2014.10.016" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256514004330?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887415000090?idApp=WRCEE" "url" => "/22548874/0000021500000005/v1_201506010556/S2254887415000090/v1_201506010556/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Brief Original" "titulo" => "Acute Q fever and the risk of developing endocarditis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "265" "paginaFinal" => "271" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Martín-Aspas, C. Collado-Pérez, L. Vela-Manzano, C. Fernández-Gutiérrez del Álamo, I. Tinoco-Racero, J.A. Girón-González" "autores" => array:6 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Martín-Aspas" "email" => array:2 [ 0 => "andres.martin.sspa@juntadeandalucia.es" 1 => "andresalapues@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Collado-Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Vela-Manzano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Fernández-Gutiérrez del Álamo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "I." "apellidos" => "Tinoco-Racero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "J.A." "apellidos" => "Girón-González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, H.U. Puerta del Mar, Cádiz, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Microbiología, H.U. Puerta del Mar, Cádiz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fiebre Q aguda: riesgo de desarrollo de endocarditis" ] ] "textoCompleto" => "<elsevierMultimedia ident="tb0005"></elsevierMultimedia>BackgroundQ fever is a zoonosis caused by C. burnetii whose acute phase clinical presentation varies between asymptomatic forms in 50–90% of patients to manifestations as variable as fever of intermediate duration, hepatitis and pneumonia.<a class="elsevierStyleCrossRef" href="#bib0120">1</a> This considerable variability appears be related to the strains prevalent in each geographical area.<a class="elsevierStyleCrossRef" href="#bib0125">2</a> In the south of Spain, 90% of symptomatic patients present with fever of intermediate duration, which is accompanied by hypertransaminasemia in 60% of patients.<a class="elsevierStyleCrossRef" href="#bib0130">3</a> The most severe clinical forms are endocarditis, vascular prosthesis infections of and aortic aneurysms, which require surgery in 15–73% of patients and cause mortality in 5–65%, depending on whether appropriate treatment is administered.<a class="elsevierStyleCrossRefs" href="#bib0135">4–7</a>Endocarditis and endovascular infections develop after an episode of acute Q fever at rates that vary between 0% and 1.5%,<a class="elsevierStyleCrossRefs" href="#bib0130">3,7–9</a> reaching rates of up to 7% in specialized centers.<a class="elsevierStyleCrossRef" href="#bib0165">10</a> The presence of prior valvular heart disease constitutes the main risk factor, although it can be asymptomatic and go unnoticed.<a class="elsevierStyleCrossRef" href="#bib0170">11</a> Due to this risk, a number of authors recommend performing transthoracic echocardiography (TTE) for all patients with acute Q fever and transesophageal echocardiography (TEE) if the phase I IgG antibodies titers are >1:800 in the first 6 months. In addition, the authors recommend starting treatment with doxycycline plus hydroxychloroquine for 1 year if valvular heart disease (bicuspid aortic valve, valvular prosthesis, moderate to serious mitral regurgitation and mitral valve prolapse) is detected.<a class="elsevierStyleCrossRefs" href="#bib0175">12–14</a> However, after an outbreak in The Netherlands, other authors found that none of the 134 patients diagnosed with acute Q fever progressed to endocarditis, despite the fact that many of them (59%) showed valvular heart disease and that none of them had undergone antibiotherapy. As a result, these authors do not recommend the systematic implementation of TTE.<a class="elsevierStyleCrossRefs" href="#bib0160">9,15</a>This study evaluated the progression to endocarditis and the prognostic value of serology for predicting the evolution of a cohort of patients with acute Q fever.Patients and methodsA retrospective study was performed at a reference hospital for cardiac surgery in the province of Cadiz, which treats a mainly urban population of 222,515 inhabitants.The patients were selected based on the positive serological results for C. burnetii between the 2000 and 2010 (indirect immunofluorescence; Q Fever IFA IgG/M, Focus Diagnostics, Cypress, CA, USA). A polymerase chain reaction (PCR) analysis for C. burnetii was not available. The patients had been initially treated in either hospital units or outpatient clinics. There was no specific established protocol for the treatment and follow-up of patients with Q fever. The use of antibiotherapy, the implementation of serological tests, echocardiography and the periodicity of checkups were therefore performed according to the individual discretion of each attending physician.Cases of acute Q fever were considered those that presented a compatible clinical condition (fever, hepatitis, pneumonia), demonstrating a pattern indicative of seroconversion in 2 successive serological measurements (initial negative serology with the presence of positive phase I or II IgM antibodies in the second reading) or a positive phase I or II IgM with an increase in at least 4 dilutions of the phase II IgG antibodies in the second reading. Cases of chronicity to endocarditis were considered those that met the modified Duke criteria (phase I IgG antibody levels≥1/800). Given that our study technique employed a double dilution method such that the value following 1:512 was 1:1024, the latter was the titer considered indicative of progression to chronicity,<a class="elsevierStyleCrossRef" href="#bib0195">16</a> as long as it was accompanied by a compatible clinical condition.The assessment of progression after the acute Q fever episode was conducted using an analysis of the medical history to 2013, so that at least 24 months had elapsed after the episode of acute Q fever in all patients. The patients included in the study only had electronic medical histories, which included all episodes of hospitalization, emergency care and primary care. We assessed data regarding febrile episodes, prolonged asthenia, increased transaminase levels, pneumonia and symptoms consistent with valve or cardiac failure, as well as data indicative of peripheral embolisms and the microbiological results (blood cultures and serology).We excluded patients who lacked medical assessments in their medical history, those who had only a single serological reading, those diagnosed with endocarditis by Q fever but with no prior episode of acute Q fever and patients with previous non-acute infections (phase I IgG antibodies titers<1:1024, with negative IgM antibodies and with no clinical condition compatible with acute Q fever).We recorded epidemiological variables (age, sex, residence), previous diseases (immunosuppression secondary to human immunodeficiency virus [HIV] infection, hematological neoplasms, treatment with steroids or immunosuppressants, previous heart disease), initial symptoms (temperature, pneumonia [respiratory symptoms with alveolar or interstitial infiltrate in chest radiography], hypertransaminasemia [serum aspartate or serum alanine aminotransferase concentrations>120IU/L, normal value<40IU/L], fever of intermediate duration [fever>38°C lasting 7–28 days, with no observed etiology after basic laboratory tests including urine element analysis and chest radiography]), fever duration, symptom persistence, chronic fatigue (intense fatigue that does not improve with rest and worsens after physical or mental effort, with normal clinical examination and basic laboratory test results), clinical data on endocarditis (valvular impairment or heart failure), number and result of serologies and treatment performed.The quantitative variables were expressed as median and interquartile range (IQR); the qualitative variables were expressed as absolute numbers and percentages. The comparison of qualitative variables between 2 groups was performed using the Chi-squared test or Fisher's exact test. The data from 2 independent groups were compared with the Mann–Whitney U test. The differences were considered statistically significant for p values <.05. The statistical analysis was performed using the SPSS program version 15.5 (SPSS Inc., Chicago, IL, USA). The study was approved by our center's ethics committee.ResultsOf the 107 patients with positive serologies, 16 were excluded for having serologies compatible with previous infection, although not acute or due to incomplete clinical data for the analysis. Another 11 cases were compatible with endocarditis by Q fever, none of which had a previous clinical episode compatible with acute Q fever. Ultimately, 80 patients diagnosed with acute Q fever were included. The majority were men (60/80, 75%) and most lived in urban areas (69/80, 86%). The most common clinical presentation was fever lasting 7–14 days, which was frequently associated with hypertransaminasemia and thrombopenia (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The median follow-up was 100 years (IQR: 76–136). Three patients (3.8%) progressed to chronic fatigue, with the remainder staying asymptomatic after the acute episode.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The serological diagnosis was performed for 32 patients (40%) by seroconversion and for 48 (60%) by increases in phase II IgG antibody titers in the second reading. Two serological readings were performed for all patients, with a median of 7 weeks between the measurements (IQR, 4–13), with 3 readings in 28 patients (35%) (20 weeks; IQR, 13–27), 4 on 12 occasions (15%) (32 weeks; IQR, 26–41) and 5 in 6 patients (7.5%) (45 weeks, IQR, 38–63).Sixteen patients (20%) had phase I IgG antibody titers≥1:1024 in the first 3 months after the episode of acute Q fever, with the phase II IgG antibodies titers always equal or greater (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Only 1 patient presented immunosuppression. TTE was performed on only 2 patients and detected degenerative valvular heart disease in both. None of the patients with phase I IgG titers≥1:1024 underwent prolonged antibiotic treatment, and none progressed to endocarditis. This patient group showed no statistically significant differences in terms of age, clinical presentation, abnormal laboratory test results or antibiotic treatment compared with the patients who did not reach phase I IgG antibody titers≥1:1024 in the first 3 months. The patients with early increases in phase I IgG antibody titers≥1:1024 presented fever lasting longer than 14 days more frequently (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>TTE was only performed on 12 patients in the entire series and detected degenerative valvular heart disease in only 2 of the patients (both with phase I IgG antibody levels≥1:1024 in the first 3 months); the other patients had normal levels. After comparing the patients who did not undergo TTE with those who did, we only found differences in terms of age, with the younger patients not undergoing TTE (median age, 41 years [IQR, 29–47] vs. 48 [IQR, 43–57]; p=.03), with no significant differences in the other analyzed variables (sex, clinical presentation, fever duration, abnormal laboratory test results and early increase in phase I IgG antibody levels).Only 35 patients (44%) underwent antibiotic treatment (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In particular, the patients whose symptoms had subsided by the time the serological results were available did not undergo antibiotherapy. The 35 treated patients showed no statistically significant differences compared with the 45 untreated patients in terms of age, sex, susceptibility to chronicity, clinical presentation, fever duration and transaminase levels. The treated patients had a significantly higher rate of serum C-reactive protein levels >10mg/dL (27/35 [77%] vs. 15/45 [33%], p<.001). Two patients underwent extended antibiotherapy, and both patients were treated with doxycycline and hydroxychloroquine. The first patient, who had no prior valvular heart disease, underwent antibiotherapy starting on the fifth month of follow-up due to phase I IgG antibody levels≥1:1024; the treatment was maintained for 12 months. The second, who had prior mitral valvular disease, underwent antibiotherapy starting the third month due to phase I IgG antibody levels of 1:4086; follow-up was lost 4 months later. The 2 patients had been treated during the acute phase and subsequently remained asymptomatic.None of the patients in the series developed endocarditis over the course of the follow-up, which lasted a median of 100 months (IQR, 76–136).DiscussionRaoult et al. observed that 100% of patients with acute Q fever who also had any type of valvular heart disease (detected by TTE or TEE), developed endocarditis in the following 2 months, unless prolonged antibiotherapy (for a year) with doxycycline and hydroxychloroquine was administered.<a class="elsevierStyleCrossRef" href="#bib0200">17</a> In this series, 7/72 included cases of acute Q fever showed early antibody titers≥1:800. Some form of valvular heart disease was detected in all of these patients, detected by TEE in the majority of cases. Systematic echocardiography and serial serologic testing was therefore recommended, especially for older patients.After an outbreak of Q fever in The Netherlands in 2007, several studies were published that showed significant differences with respect to the previously mentioned recommendations for preventing endocarditis by C. burnetii. Van der Hoek et al. found a low rate of progression to endocarditis (3/686 cases, 0.5%),<a class="elsevierStyleCrossRef" href="#bib0205">18</a> even when the patients presented prior degenerative valvular heart disease<a class="elsevierStyleCrossRef" href="#bib0160">9</a> or phase I IgG levels≥1:800 during the first 3 months of evolution.<a class="elsevierStyleCrossRef" href="#bib0205">18</a> Another publication defined a history of previous valve surgery, vascular prosthesis, aneurysms, renal failure and an age over 60 years as risk factors for developing chronic C. burnetii infection.<a class="elsevierStyleCrossRef" href="#bib0210">19</a> In light of these results, the authors do not recommend performing TTE for all patients or prolonged treatment based solely on the serological results.Our data disagree with the findings of Raoult et al.<a class="elsevierStyleCrossRef" href="#bib0200">17</a> and agree with the observations of other authors, including those of a Spanish series in which there were no cases of progression to endocarditis.<a class="elsevierStyleCrossRefs" href="#bib0130">3,20</a> As with these series, our experience has been that the early increase in phase I IgG antibody levels is not associated with a subsequent progression to endocarditis.<a class="elsevierStyleCrossRefs" href="#bib0130">3,18,20</a>In our series, only 16/80 (20%) of the patients included in the study presented phase I IgG titers≥1:1024 during the first 3 months. For all patients in the series, except for 2 cases in which prolonged treatment was administered, the therapy applied was the acute Q fever therapy. However, a number of patients who were asymptomatic by the time the serological results were available were not treated. None of the patients developed endocarditis. It can be argued that the lack of systematic echocardiography detracts from the validity of this finding. However, although 6% of cases of endocarditis by Coxiella can be asymptomatic,<a class="elsevierStyleCrossRef" href="#bib0140">5</a> the lack of clinical data over the course of the highly prolonged progression in our series is surprising.A number of authors have proposed that phase I IgG antibody titers ≥1:6400 should be considered a major criterion of endocarditis and that titers <1:6400 but ≥1:800 such be considered a minor criterion, thereby achieving a positive predictive value of 75% for endocarditis.<a class="elsevierStyleCrossRefs" href="#bib0180">13,21</a> The definitive diagnosis of endocarditis requires isolates from the surgically removed heart valve (cultures, CRP or immunohistochemistry) or, lacking valve tissue, the presence of clinical symptoms compatible with chronic infection/valve dysfunction along with other major or minor clinical criteria. According to other authors, the diagnosis of chronic Q fever should be based on clinical data, due to the observed variability in the serologic values and results of the CRP technique,<a class="elsevierStyleCrossRef" href="#bib0205">18</a> although they consider that chronic Q fever is proven when there is a positive CRP result in blood or tissue after surgery.<a class="elsevierStyleCrossRef" href="#bib0210">19</a> None of our patients showed phase I IgG antibody titers ≥1:6400 over time or symptoms suggestive of chronicity.In the previously mentioned series, the development of endocarditis was correlated with age (mean of 66 years in the Dutch group and older than 40 years in the French group). The factors that could justify the non-progression to endocarditis in our patients include the fact that these were young individuals in whom the prevalence of prior valvular heart disease was low, given that this prevalence is estimated at 0.7% in patients younger than 54 years.<a class="elsevierStyleCrossRef" href="#bib0225">22</a> Surprisingly, in the French study, the prevalence of valvular heart disease at this age reached 45%. It is possible that the differences observed between the various studies could be due to selection biases according to the type of center and study population and to differences in the circulating strains in each area.<a class="elsevierStyleCrossRef" href="#bib0180">13</a>Our study's limitations include its retrospective character, the fact that it was conducted in a single center and the lack of a pre-established protocol for the care of these patients. Many of our patients did not therefore undergo extended serologic follow-up or echocardiographic studies. Thus, cases of subclinical endocarditis might have gone undiagnosed. However, none of the patients were carriers of valvular or vascular prosthesis or required valve surgery over the course of their evolution. Moreover, CRP tests in blood were not conducted for all patients, which could have detected cases of asymptomatic chronic Q fever (estimated sensitivity of 33–64%).<a class="elsevierStyleCrossRef" href="#bib0230">23</a>Based on our results, it appears that the detection in asymptomatic patients of phase I IgG antibody levels ≥1:1024 in the first 3 months after an episode of acute Q fever, even when prolonged antibiotherapy is not provided, is not associated with progression to endocarditis. The diagnostic–therapeutic approach after an episode of acute Q fever should be based mainly on the established risk factors or the presence of clinical symptoms.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres519455" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec539980" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres519456" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec539979" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-11-09" "fechaAceptado" => "2015-01-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec539980" "palabras" => array:6 [ 0 => "Q fever" 1 => "Coxiella burnetii" 2 => "Endocarditis" 3 => "Serology" 4 => "Echocardiogram" 5 => "Prevention" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec539979" "palabras" => array:6 [ 0 => "Fiebre Q" 1 => "Coxiella burnetii" 2 => "Endocarditis" 3 => "Serología" 4 => "Ecocardiograma" 5 => "Prevención" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesAssess clinical and serological data as parameters indicative of a possible evolution to endocarditis after an episode of acute Q fever. Patients and methodsRetrospective cohort study of evolution to endocarditis after an acute Q fever episode, analyzing the clinical and serological evolution and the antibiotic treatment administered. ResultsEighty patients were recruited, 20% of whom had phase I IgG antibody levels≥1:1024 in the first 3 months. Only 44% of the patients underwent antibiotherapy in the acute phase; only 2 patients underwent extended antibiotherapy. Fifteen percent of the patients underwent an echocardiogram. None of the patients had symptoms suggestive of chronic infection or progressed to endocarditis after a median follow-up of 100 months, regardless of the early increase in phase I IgG antibodies. ConclusionsThe early increase in phase I IgG antibodies in asymptomatic patients is not associated with progression to endocarditis despite not undergoing prolonged antibiotic treatment." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoValorar los datos clínicos y serológicos como parámetros indicativos de posible evolución a endocarditis tras un episodio de fiebre Q aguda. Pacientes y métodosEstudio de cohortes retrospectivo de la evolución a endocarditis tras un episodio de fiebre Q aguda, analizando evolución clínica, serológica y tratamiento antibiótico recibido. ResultadosSe reclutó a 80 pacientes, presentando el 20% niveles de anticuerpos IgG de fase i ≥ 1:1.024 en los primeros 3 meses. Solo el 44% recibió antibioterapia en la fase aguda; únicamente 2 enfermos recibieron antibioterapia prolongada. Se realizó ecocardiograma al 15%. Ningún paciente presentó síntomas indicativos de infección crónica ni evolucionó a endocarditis tras una mediana de seguimiento de 100 meses, independientemente de la elevación precoz de anticuerpos IgG de fase i. ConclusionesLa elevación precoz de anticuerpos IgG fase i no se asoció a evolución a endocarditis a pesar de no haberse realizado tratamiento antibiótico prolongado en pacientes asintomáticos." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Martín-Aspas A, Collado-Pérez C, Vela-Manzano L, Fernández-Gutiérrez del Álamo C, Tinoco-Racero I, Girón-González JA. Fiebre Q aguda: riesgo de desarrollo de endocarditis. Rev Clin Esp. 2015;215:265–271." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviations: ALT, alanine amino transaminase; AST, aspartate amino transaminase." "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=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age, years (interquartile range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (30–51) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male sex, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (75) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Urban residence, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 (86) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Temperature>38°C, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 (98) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Fever duration, n (%)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><7 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">7–14 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44 (55) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">>14 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Clinical presentation, n (%)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hypertransaminasemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (63) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Unexplained fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (20) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (17) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chronic asthenia up to 6 months later, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Immunosuppression, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Platelet count<150,000/μl, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 (49) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">AST>120 U/L, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (40) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ALT>120 U/L, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 (54) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chest radiography conducted/pathological, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (39)/6 (8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">C-reactive protein>10mg/dL, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (53) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Abdominal ultrasound performed, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (43) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hepatomegaly, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (16) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Splenomegaly, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Transthoracic echocardiography performed/pathological, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (15)/2 (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Treated with doxycycline, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (42) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Duration in days, n (interquartile range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (14–21) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Treated with ciprofloxacin, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Duration in days, n (interquartile range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (14–90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patients with combined treatment, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab838199.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Epidemiological, clinical and laboratory data on the 80 patients with acute Q fever included in this study." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviations: CIP, doxycycline; DXC, doxycycline; HCL, hydroxychloroquine; NA, not available; NP, not performed; susceptibility to chronicity, presence of valvular heart disease or immunosuppression." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age, years \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Delay in initial serology, weeks \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Susceptibility to chronicity \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Echocardiogram \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum phase I/II IgG in first 3 months \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Final phase I/II IgG (difference in weeks) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up, months \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiotic therapy \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1024/1024 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">118 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DXC 21 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1024/4096 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">512/512 (112) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DXC 21 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Aortic valve disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4096/8192 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1024/2048 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DXC 14 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1024/1024 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">147 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4096/4096 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1024/2048 (16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">148 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DXC 14 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1024/4096 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2048/2048 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">112 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2048/8192 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DXC+CIP 14 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4096/8192 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1024/4096 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">141 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1024/1024 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2048/2048 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">158 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DXC 14 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1024/1024 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1024/4096 (12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DXC 21 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mitral valve disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4086/8172 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">512/512 (16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DXC+HCL 3 months \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8192/8192 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">256/512 (31) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DXC 14 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1024/2048 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">512/256 (32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">136 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8192/16,384 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4096/8192 (20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">152 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab838201.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patients with phase I IgG values ≥1:1024 in the first 3 months of acute Q fever: serological evolution and prescribed antibiotherapy." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviations: ALT, alanine amino transaminase; AST, aspartate amino transaminase." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Increase in phase 1 IgG antibody levels (> 1:1024) in the first 3 months</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No (64 patients) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes (16 patients) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Median age, years (interquartile range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (29–49) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44 (32–56) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.582 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male sex, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 (72) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (87) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.333 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Clinical presentation, n (%)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hypertransaminasemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (59) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.386 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Unexplained fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (31) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.364 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Fever duration, n (%)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><7 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (33) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.069 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">7–14 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 (56) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.866 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">>14 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (38) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.015 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Increased transaminase levels, n (%)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">AST>120U/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (44) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.278 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ALT>120U/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 (56) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (44) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.537 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Platelet count <150,000/μL, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (47) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (56) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.695 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">C-reactive protein >10mg/dL, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (52) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (56) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.955 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Treatment with doxycycline, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (38) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (56) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.281 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab838200.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Differences in the epidemiological, clinical and laboratory variables between the patients with and without an increase in phase I IgG antibodies ≥1:1024 in the first 3 months." ] ] 3 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "What we know?Endocarditis and endovascular infections develop after an episode of acute Q fever in 0% and 1.5% of cases. The presence of prior valvular heart disease constitutes the main risk factor. There has therefore been debate about the advisability of performing transthoracic echocardiography (TTE) for all patients with acute Q fever and, in the event that valvular heart disease is detected, starting treatment with doxycycline plus hydroxychloroquine for a year. This study evaluates the progression to endocarditis and the prognostic value of serology for a cohort of patients with acute Q fever.What this article provides?None of the 80 patients with acute Q fever included in this study progressed to endocarditis. The early increase in the levels of phase 1 antibodies against Coxiella burnetti had no prognostic value.The Editors" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Natural history and pathophysiology of Q fever" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Raoult" 1 => "T. Marrie" 2 => "J. Mege" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1473-3099(05)70052-9" "Revista" => array:6 [ "tituloSerie" => "Lancet Infect Dis" "fecha" => "2005" "volumen" => "5" "paginaInicial" => "219" "paginaFinal" => "226" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15792739" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0125" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coxiella burnetii genotyping" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "O. Glazunova" 1 => "V. Roux" 2 => "O. Freylikman" 3 => "Z. Sekeyova" 4 => "G. Fournous" 5 => "J. Tyczka" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3201/eid1108.041354" "Revista" => array:6 [ "tituloSerie" => "Emerg Infect Dis" "fecha" => "2005" "volumen" => "11" "paginaInicial" => "1211" "paginaFinal" => "1217" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16102309" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0130" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Q fever: epidemiology, clinical features and prognosis. A study from 1983 to 1999 in the South of Spain" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. De Alarcón" 1 => "J.L. Villanueva" 2 => "P. Viciana" 3 => "L. López-Cortés" 4 => "R. Torronteras" 5 => "M. Bernabeu" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Infect" "fecha" => "2003" "volumen" => "47" "paginaInicial" => "110" "paginaFinal" => "116" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12860143" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0135" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endocarditis por fiebre Q en España. Características clínicas y evolución" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.V. Mogollón" 1 => "M.P. Anguita" 2 => "J.M. Aguado" 3 => "P. Tornos" 4 => "J.M. Miró" 5 => "J. Gálvez-Acebal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2010.07.015" "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2011" "volumen" => "29" "paginaInicial" => "109" "paginaFinal" => "116" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21333397" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0140" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term outcome of Q fever endocarditis: a 26-year personal survey" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Million" 1 => "F. Thuny" 2 => "H. Richet" 3 => "D. Raoult" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1473-3099(10)70135-3" "Revista" => array:6 [ "tituloSerie" => "Lancet Infect Dis" "fecha" => "2010" "volumen" => "10" "paginaInicial" => "527" "paginaFinal" => "535" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20637694" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0145" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Q fever 1985–1998. Clinical and epidemiologic features of 1383 infections" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Raoult" 1 => "H. Tissot-Dupont" 2 => "C. Foucault" 3 => "J. Gouvernet" 4 => "P.E. Forunier" 5 => "E. Bernit" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Medicine (Baltimore)" "fecha" => "2000" "volumen" => "79" "paginaInicial" => "109" "paginaFinal" => "123" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0150" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic Q fever in the Netherlands 5 years after the start of the Q fever epidemic: results from the Dutch Chronic Q fever database" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L.M. Kampschreur" 1 => "C.E. Delsing" 2 => "R.H. Groenwold" 3 => "M.C. Wegdam-Blas" 4 => "C.P. Bleeker-Rovers" 5 => "M.G. de Jager-Leclercq" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/JCM.03221-13" "Revista" => array:6 [ "tituloSerie" => "J Clin Microbiol" "fecha" => "2014" "volumen" => "52" "paginaInicial" => "1637" "paginaFinal" => "1643" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24599987" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0155" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gipuzkoa, Basque Country, Spain (1984–2004): a hyperendemic area of Q fever" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Montes" 1 => "G. Cilla" 2 => "D. Vicente" 3 => "V. Nieto" 4 => "M. Ercibengoa" 5 => "E. Perez-Trallero" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1196/annals.1374.020" "Revista" => array:6 [ "tituloSerie" => "Ann N Y Acad Sci" "fecha" => "2006" "volumen" => "1078" "paginaInicial" => "129" "paginaFinal" => "132" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17114693" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0160" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevention of Q fever endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G.J. Limonard" 1 => "M.H. Nabuurs-Franssen" 2 => "P.N. Dekhuijzen" 3 => "C.A. Groot" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1473-3099(11)70016-0" "Revista" => array:6 [ "tituloSerie" => "Lancet Infect Dis" "fecha" => "2011" "volumen" => "11" "paginaInicial" => "82" "paginaFinal" => "83" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21272791" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0165" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risks factors and prevention of Q fever endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F. Fenollar" 1 => "P.E. Fournier" 2 => "M.P. Carrieri" 3 => "G. Habib" 4 => "T. Messana" 5 => "D. Raoult" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/321889" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2001" "volumen" => "33" "paginaInicial" => "312" "paginaFinal" => "316" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11438895" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0170" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endocarditis after acute Q fever in patients with previously undiagnosed valvulopathies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "F. Fenollar" 1 => "F. Thuny" 2 => "B. Xeridat" 3 => "H. Lepidi" 4 => "D. Raoult" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/500402" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2006" "volumen" => "42" "paginaInicial" => "818" "paginaFinal" => "821" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16477559" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0175" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "From acute Q fever to endocarditis: serological follow-up strategy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Landais" 1 => "F. Fenollar" 2 => "F. Thuny" 3 => "D. Raoult" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/515401" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2007" "volumen" => "44" "paginaInicial" => "1337" "paginaFinal" => "1340" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17443471" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0180" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic Q fever: expert opinion versus literature analysis and consensus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. Raoult" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jinf.2012.04.006" "Revista" => array:6 [ "tituloSerie" => "J Infect" "fecha" => "2012" "volumen" => "65" "paginaInicial" => "102" "paginaFinal" => "108" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22537659" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0185" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reduction in incidence of Q fever endocarditis: 27 years of experience of a national reference center" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. Edouard" 1 => "M. Million" 2 => "G. Royer" 3 => "R. Giorgi" 4 => "D. Grisoli" 5 => "D. Raoult" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jinf.2013.10.010" "Revista" => array:6 [ "tituloSerie" => "J Infect" "fecha" => "2014" "volumen" => "68" "paginaInicial" => "141" "paginaFinal" => "148" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24183890" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0190" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "One-year follow-up of patients of the ongoing Dutch Q fever outbreak: clinical, serological and echocardiographic findings" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.J. Limonard" 1 => "M.H. Nabuurs-Franssen" 2 => "G. Weers-Pothoff" 3 => "C. Wijkmans" 4 => "R. Besselink" 5 => "A.M. Horrevorts" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s15010-010-0052-x" "Revista" => array:6 [ "tituloSerie" => "Infection" "fecha" => "2010" "volumen" => "38" "paginaInicial" => "471" "paginaFinal" => "477" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20857313" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0195" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.S. Li" 1 => "D.J. Sexton" 2 => "N. Mick" 3 => "R. Nettles" 4 => "V.G. Fowler Jr." 5 => "T. Ryan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/313753" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2000" "volumen" => "30" "paginaInicial" => "633" "paginaFinal" => "638" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10770721" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0200" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolution from acute Q fever to endocarditis is associated with underlying valvulopathy and age and can be prevented by prolonged antibiotic treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Million" 1 => "G. Walter" 2 => "F. Thuny" 3 => "G. Habib" 4 => "D. Raoult" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/cid/cit419" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2013" "volumen" => "57" "paginaInicial" => "836" "paginaFinal" => "844" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23794723" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0205" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Follow-up of 686 patients with acute Q fever and detection of chronic infection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W. Van der Hoek" 1 => "B. Versteeg" 2 => "J. Meekelenkamp" 3 => "N. Renders" 4 => "A. Leenders" 5 => "I. Weers-Pothoff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/cid/cir234" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2011" "volumen" => "52" "paginaInicial" => "1431" "paginaFinal" => "1436" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21628483" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0210" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Identification of risk factors for chronic Q fever, the Netherlands" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L.M. Kampschreur" 1 => "S. Dekker" 2 => "J. Hagenaars" 3 => "P. Lestrade" 4 => "N. Renders" 5 => "M. de Jager-Leclercq" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3201/eid1804.111478" "Revista" => array:6 [ "tituloSerie" => "Emerg Infect Dis" "fecha" => "2012" "volumen" => "18" "paginaInicial" => "563" "paginaFinal" => "570" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22469535" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0215" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Serologic assessment of the risk of developing chronic Q fever in cohorts of acutely infected individuals" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.N. Hung" 1 => "L.J. Lin" 2 => "M.Y. Hou" 3 => "P.S. Lin" 4 => "Y.C. Wang" 5 => "P.Y. Shu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jinf.2010.10.008" "Revista" => array:6 [ "tituloSerie" => "J Infect" "fecha" => "2011" "volumen" => "62" "paginaInicial" => "39" "paginaFinal" => "44" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21034771" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0220" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ongoing queries: interpretation of serology in asymptomatic or atypical chronic Q fever" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. De Silva" 1 => "A. Chapman" 2 => "G. Kudesia" 3 => "M. McKendrick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jinf.2005.07.024" "Revista" => array:6 [ "tituloSerie" => "J Infect" "fecha" => "2006" "volumen" => "52" "paginaInicial" => "e113" "paginaFinal" => "e116" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16126277" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0225" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Burden of valvular heart diseases: a population-based study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "V.T. Nkomo" 1 => "J.M. Gardin" 2 => "T.N. Skelton" 3 => "J.S. Gottdiener" 4 => "C.G. Scott" 5 => "M. Enriquez-Sarano" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(06)69208-8" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2006" "volumen" => "368" "paginaInicial" => "1005" "paginaFinal" => "1011" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16980116" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0230" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and management of Q fever – United States, 2013: recommendations from CDC and the Q fever working group" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Anderson" 1 => "H. Bijlmer" 2 => "P.E. Fournier" 3 => "S. Graves" 4 => "J. Hartzell" 5 => "G.J. Kersh" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "MMWR Recomm Rep" "fecha" => "2013" "volumen" => "62" "paginaInicial" => "1" "paginaFinal" => "30" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24352112" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000021500000005/v1_201506010556/S2254887415000387/v1_201506010556/en/main.assets" "Apartado" => array:4 [ "identificador" => "1903" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Brief Original" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021500000005/v1_201506010556/S2254887415000387/v1_201506010556/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887415000387?idApp=WRCEE"]

Statistics

Brief Original

Acute Q fever and the risk of developing endocarditis

Fiebre Q aguda: riesgo de desarrollo de endocarditis

A. Martín-Aspasa,

Corresponding author

andres.martin.sspa@juntadeandalucia.es
andresalapues@hotmail.com

Corresponding author.

, C. Collado-Péreza, L. Vela-Manzanoa, C. Fernández-Gutiérrez del Álamob, I. Tinoco-Raceroa, J.A. Girón-Gonzáleza

a Servicio de Medicina Interna, H.U. Puerta del Mar, Cádiz, Spain

b Servicio de Microbiología, H.U. Puerta del Mar, Cádiz, Spain

Read

Times
was read the article

Total PDF

Total HTML

Share statistics

 array:23 [
  "pii" => "S2254887415000387"
  "issn" => "22548874"
  "doi" => "10.1016/j.rceng.2015.01.003"
  "estado" => "S300"
  "fechaPublicacion" => "2015-06-01"
  "aid" => "1112"
  "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;"
  "copyrightAnyo" => "2015"
  "documento" => "article"
  "subdocumento" => "sco"
  "cita" => "Rev Clin Esp. 2015;215:265-71"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 78
    "formatos" => array:2 [
      "HTML" => 75
      "PDF" => 3
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:18 [
      "pii" => "S0014256515000521"
      "issn" => "00142565"
      "doi" => "10.1016/j.rce.2015.01.011"
      "estado" => "S300"
      "fechaPublicacion" => "2015-06-01"
      "aid" => "1112"
      "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; y Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;"
      "documento" => "article"
      "subdocumento" => "sco"
      "cita" => "Rev Clin Esp. 2015;215:265-71"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:2 [
        "total" => 666
        "formatos" => array:2 [
          "HTML" => 358
          "PDF" => 308
        ]
      ]
      "es" => array:12 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">ORIGINAL BREVE</span>"
        "titulo" => "Fiebre Q aguda&#58; riesgo de desarrollo de endocarditis"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "265"
            "paginaFinal" => "271"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Acute Q fever and the risk of developing endocarditis"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "A&#46; Mart&#237;n-Aspas, C&#46; Collado-P&#233;rez, L&#46; Vela-Manzano, C&#46; Fern&#225;ndez-Guti&#233;rrez del &#193;lamo, I&#46; Tinoco-Racero, J&#46;A&#46; Gir&#243;n-Gonz&#225;lez"
            "autores" => array:6 [
              0 => array:2 [
                "nombre" => "A&#46;"
                "apellidos" => "Mart&#237;n-Aspas"
              ]
              1 => array:2 [
                "nombre" => "C&#46;"
                "apellidos" => "Collado-P&#233;rez"
              ]
              2 => array:2 [
                "nombre" => "L&#46;"
                "apellidos" => "Vela-Manzano"
              ]
              3 => array:2 [
                "nombre" => "C&#46;"
                "apellidos" => "Fern&#225;ndez-Guti&#233;rrez del &#193;lamo"
              ]
              4 => array:2 [
                "nombre" => "I&#46;"
                "apellidos" => "Tinoco-Racero"
              ]
              5 => array:2 [
                "nombre" => "J&#46;A&#46;"
                "apellidos" => "Gir&#243;n-Gonz&#225;lez"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2254887415000387"
          "doi" => "10.1016/j.rceng.2015.01.003"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887415000387?idApp=WRCEE"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256515000521?idApp=WRCEE"
      "url" => "/00142565/0000021500000005/v1_201506010559/S0014256515000521/v1_201506010559/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:18 [
    "pii" => "S2254887415000272"
    "issn" => "22548874"
    "doi" => "10.1016/j.rceng.2015.03.001"
    "estado" => "S300"
    "fechaPublicacion" => "2015-06-01"
    "aid" => "1100"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;"
    "documento" => "simple-article"
    "subdocumento" => "crp"
    "cita" => "Rev Clin Esp. 2015;215:276-84"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 121
      "formatos" => array:2 [
        "HTML" => 119
        "PDF" => 2
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Clinical up-date</span>"
      "titulo" => "Pernicious anemia&#46; From past to present"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "276"
          "paginaFinal" => "284"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Anemia perniciosa&#46; Del pasado al presente"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 2181
              "Ancho" => 3250
              "Tamanyo" => 602672
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pathophysiology of vitamin B12 absorption and deficiency&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "E&#46; Rodr&#237;guez de Santiago, C&#46; Ferre Aracil, A&#46; Garc&#237;a Garc&#237;a de Paredes, V&#46;F&#46; Moreira Vicente"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "E&#46;"
              "apellidos" => "Rodr&#237;guez de Santiago"
            ]
            1 => array:2 [
              "nombre" => "C&#46;"
              "apellidos" => "Ferre Aracil"
            ]
            2 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Garc&#237;a Garc&#237;a de Paredes"
            ]
            3 => array:2 [
              "nombre" => "V&#46;F&#46;"
              "apellidos" => "Moreira Vicente"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S001425651500003X"
        "doi" => "10.1016/j.rce.2014.12.013"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S001425651500003X?idApp=WRCEE"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887415000272?idApp=WRCEE"
    "url" => "/22548874/0000021500000005/v1_201506010556/S2254887415000272/v1_201506010556/en/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S2254887415000090"
    "issn" => "22548874"
    "doi" => "10.1016/j.rceng.2015.01.001"
    "estado" => "S300"
    "fechaPublicacion" => "2015-06-01"
    "aid" => "1073"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;"
    "documento" => "article"
    "subdocumento" => "fla"
    "cita" => "Rev Clin Esp. 2015;215:258-64"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 63
      "formatos" => array:2 [
        "HTML" => 61
        "PDF" => 2
      ]
    ]
    "en" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
      "titulo" => "Has the time come to search for the Wells score 4&#46;0&#63;"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "258"
          "paginaFinal" => "264"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "&#191;Ha llegado el momento de buscar la escala de Wells 4&#46;0&#63;"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "F&#46; Rosa-Jim&#233;nez, A&#46; Rosa-Jim&#233;nez, A&#46; Lozano-Rodr&#237;guez, P&#46; Mart&#237;n-Moreno, M&#46;D&#46; Hinojosa-Mart&#237;nez, &#193;&#46;M&#46; Montijano-Cabrera"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "F&#46;"
              "apellidos" => "Rosa-Jim&#233;nez"
            ]
            1 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Rosa-Jim&#233;nez"
            ]
            2 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Lozano-Rodr&#237;guez"
            ]
            3 => array:2 [
              "nombre" => "P&#46;"
              "apellidos" => "Mart&#237;n-Moreno"
            ]
            4 => array:2 [
              "nombre" => "M&#46;D&#46;"
              "apellidos" => "Hinojosa-Mart&#237;nez"
            ]
            5 => array:2 [
              "nombre" => "&#193;&#46;M&#46;"
              "apellidos" => "Montijano-Cabrera"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0014256514004330"
        "doi" => "10.1016/j.rce.2014.10.016"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256514004330?idApp=WRCEE"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887415000090?idApp=WRCEE"
    "url" => "/22548874/0000021500000005/v1_201506010556/S2254887415000090/v1_201506010556/en/main.assets"
  ]
  "en" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Brief Original</span>"
    "titulo" => "Acute Q fever and the risk of developing endocarditis"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "265"
        "paginaFinal" => "271"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "A&#46; Mart&#237;n-Aspas, C&#46; Collado-P&#233;rez, L&#46; Vela-Manzano, C&#46; Fern&#225;ndez-Guti&#233;rrez del &#193;lamo, I&#46; Tinoco-Racero, J&#46;A&#46; Gir&#243;n-Gonz&#225;lez"
        "autores" => array:6 [
          0 => array:4 [
            "nombre" => "A&#46;"
            "apellidos" => "Mart&#237;n-Aspas"
            "email" => array:2 [
              0 => "andres&#46;martin&#46;sspa&#64;juntadeandalucia&#46;es"
              1 => "andresalapues&#64;hotmail&#46;com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "C&#46;"
            "apellidos" => "Collado-P&#233;rez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "L&#46;"
            "apellidos" => "Vela-Manzano"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "C&#46;"
            "apellidos" => "Fern&#225;ndez-Guti&#233;rrez del &#193;lamo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "I&#46;"
            "apellidos" => "Tinoco-Racero"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "J&#46;A&#46;"
            "apellidos" => "Gir&#243;n-Gonz&#225;lez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Servicio de Medicina Interna&#44; H&#46;U&#46; Puerta del Mar&#44; C&#225;diz&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Servicio de Microbiolog&#237;a&#44; H&#46;U&#46; Puerta del Mar&#44; C&#225;diz&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Fiebre Q aguda&#58; riesgo de desarrollo de endocarditis"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0145" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Background</span><p id="par0020" class="elsevierStylePara elsevierViewall">Q fever is a zoonosis caused by <span class="elsevierStyleItalic">C&#46; burnetii</span> whose acute phase clinical presentation varies between asymptomatic forms in 50&#8211;90&#37; of patients to manifestations as variable as fever of intermediate duration&#44; hepatitis and pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> This considerable variability appears be related to the strains prevalent in each geographical area&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> In the south of Spain&#44; 90&#37; of symptomatic patients present with fever of intermediate duration&#44; which is accompanied by hypertransaminasemia in 60&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> The most severe clinical forms are endocarditis&#44; vascular prosthesis infections of and aortic aneurysms&#44; which require surgery in 15&#8211;73&#37; of patients and cause mortality in 5&#8211;65&#37;&#44; depending on whether appropriate treatment is administered&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4&#8211;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Endocarditis and endovascular infections develop after an episode of acute Q fever at rates that vary between 0&#37; and 1&#46;5&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#44;7&#8211;9</span></a> reaching rates of up to 7&#37; in specialized centers&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> The presence of prior valvular heart disease constitutes the main risk factor&#44; although it can be asymptomatic and go unnoticed&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> Due to this risk&#44; a number of authors recommend performing transthoracic echocardiography &#40;TTE&#41; for all patients with acute Q fever and transesophageal echocardiography &#40;TEE&#41; if the phase I IgG antibodies titers are &#62;1&#58;800 in the first 6 months&#46; In addition&#44; the authors recommend starting treatment with doxycycline plus hydroxychloroquine for 1 year if valvular heart disease &#40;bicuspid aortic valve&#44; valvular prosthesis&#44; moderate to serious mitral regurgitation and mitral valve prolapse&#41; is detected&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">12&#8211;14</span></a> However&#44; after an outbreak in The Netherlands&#44; other authors found that none of the 134 patients diagnosed with acute Q fever progressed to endocarditis&#44; despite the fact that many of them &#40;59&#37;&#41; showed valvular heart disease and that none of them had undergone antibiotherapy&#46; As a result&#44; these authors do not recommend the systematic implementation of TTE&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">9&#44;15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This study evaluated the progression to endocarditis and the prognostic value of serology for predicting the evolution of a cohort of patients with acute Q fever&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A retrospective study was performed at a reference hospital for cardiac surgery in the province of Cadiz&#44; which treats a mainly urban population of 222&#44;515 inhabitants&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patients were selected based on the positive serological results for <span class="elsevierStyleItalic">C&#46; burnetii</span> between the 2000 and 2010 &#40;indirect immunofluorescence&#59; Q Fever IFA IgG&#47;M&#44; Focus Diagnostics&#44; Cypress&#44; CA&#44; USA&#41;&#46; A polymerase chain reaction &#40;PCR&#41; analysis for <span class="elsevierStyleItalic">C&#46; burnetii</span> was not available&#46; The patients had been initially treated in either hospital units or outpatient clinics&#46; There was no specific established protocol for the treatment and follow-up of patients with Q fever&#46; The use of antibiotherapy&#44; the implementation of serological tests&#44; echocardiography and the periodicity of checkups were therefore performed according to the individual discretion of each attending physician&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Cases of acute Q fever were considered those that presented a compatible clinical condition &#40;fever&#44; hepatitis&#44; pneumonia&#41;&#44; demonstrating a pattern indicative of seroconversion in 2 successive serological measurements &#40;initial negative serology with the presence of positive phase I or II IgM antibodies in the second reading&#41; or a positive phase I or II IgM with an increase in at least 4 dilutions of the phase II IgG antibodies in the second reading&#46; Cases of chronicity to endocarditis were considered those that met the modified Duke criteria &#40;phase I IgG antibody levels<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#47;800&#41;&#46; Given that our study technique employed a double dilution method such that the value following 1&#58;512 was 1&#58;1024&#44; the latter was the titer considered indicative of progression to chronicity&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> as long as it was accompanied by a compatible clinical condition&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The assessment of progression after the acute Q fever episode was conducted using an analysis of the medical history to 2013&#44; so that at least 24 months had elapsed after the episode of acute Q fever in all patients&#46; The patients included in the study only had electronic medical histories&#44; which included all episodes of hospitalization&#44; emergency care and primary care&#46; We assessed data regarding febrile episodes&#44; prolonged asthenia&#44; increased transaminase levels&#44; pneumonia and symptoms consistent with valve or cardiac failure&#44; as well as data indicative of peripheral embolisms and the microbiological results &#40;blood cultures and serology&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We excluded patients who lacked medical assessments in their medical history&#44; those who had only a single serological reading&#44; those diagnosed with endocarditis by Q fever but with no prior episode of acute Q fever and patients with previous non-acute infections &#40;phase I IgG antibodies titers<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#58;1024&#44; with negative IgM antibodies and with no clinical condition compatible with acute Q fever&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We recorded epidemiological variables &#40;age&#44; sex&#44; residence&#41;&#44; previous diseases &#40;immunosuppression secondary to human immunodeficiency virus &#91;HIV&#93; infection&#44; hematological neoplasms&#44; treatment with steroids or immunosuppressants&#44; previous heart disease&#41;&#44; initial symptoms &#40;temperature&#44; pneumonia &#91;respiratory symptoms with alveolar or interstitial infiltrate in chest radiography&#93;&#44; hypertransaminasemia &#91;serum aspartate or serum alanine aminotransferase concentrations<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>120<span class="elsevierStyleHsp" style=""></span>IU&#47;L&#44; normal value<span class="elsevierStyleHsp" style=""></span>&#60;40<span class="elsevierStyleHsp" style=""></span>IU&#47;L&#93;&#44; fever of intermediate duration &#91;fever<span class="elsevierStyleHsp" style=""></span>&#62;38<span class="elsevierStyleHsp" style=""></span>&#176;C lasting 7&#8211;28 days&#44; with no observed etiology after basic laboratory tests including urine element analysis and chest radiography&#93;&#41;&#44; fever duration&#44; symptom persistence&#44; chronic fatigue &#40;intense fatigue that does not improve with rest and worsens after physical or mental effort&#44; with normal clinical examination and basic laboratory test results&#41;&#44; clinical data on endocarditis &#40;valvular impairment or heart failure&#41;&#44; number and result of serologies and treatment performed&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The quantitative variables were expressed as median and interquartile range &#40;IQR&#41;&#59; the qualitative variables were expressed as absolute numbers and percentages&#46; The comparison of qualitative variables between 2 groups was performed using the Chi-squared test or Fisher&#39;s exact test&#46; The data from 2 independent groups were compared with the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#46; The differences were considered statistically significant for <span class="elsevierStyleItalic">p</span> values &#60;&#46;05&#46; The statistical analysis was performed using the SPSS program version 15&#46;5 &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46; The study was approved by our center&#39;s ethics committee&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">Of the 107 patients with positive serologies&#44; 16 were excluded for having serologies compatible with previous infection&#44; although not acute or due to incomplete clinical data for the analysis&#46; Another 11 cases were compatible with endocarditis by Q fever&#44; none of which had a previous clinical episode compatible with acute Q fever&#46; Ultimately&#44; 80 patients diagnosed with acute Q fever were included&#46; The majority were men &#40;60&#47;80&#44; 75&#37;&#41; and most lived in urban areas &#40;69&#47;80&#44; 86&#37;&#41;&#46; The most common clinical presentation was fever lasting 7&#8211;14 days&#44; which was frequently associated with hypertransaminasemia and thrombopenia &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The median follow-up was 100 years &#40;IQR&#58; 76&#8211;136&#41;&#46; Three patients &#40;3&#46;8&#37;&#41; progressed to chronic fatigue&#44; with the remainder staying asymptomatic after the acute episode&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The serological diagnosis was performed for 32 patients &#40;40&#37;&#41; by seroconversion and for 48 &#40;60&#37;&#41; by increases in phase II IgG antibody titers in the second reading&#46; Two serological readings were performed for all patients&#44; with a median of 7 weeks between the measurements &#40;IQR&#44; 4&#8211;13&#41;&#44; with 3 readings in 28 patients &#40;35&#37;&#41; &#40;20 weeks&#59; IQR&#44; 13&#8211;27&#41;&#44; 4 on 12 occasions &#40;15&#37;&#41; &#40;32 weeks&#59; IQR&#44; 26&#8211;41&#41; and 5 in 6 patients &#40;7&#46;5&#37;&#41; &#40;45 weeks&#44; IQR&#44; 38&#8211;63&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Sixteen patients &#40;20&#37;&#41; had phase I IgG antibody titers<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#58;1024 in the first 3 months after the episode of acute Q fever&#44; with the phase II IgG antibodies titers always equal or greater &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Only 1 patient presented immunosuppression&#46; TTE was performed on only 2 patients and detected degenerative valvular heart disease in both&#46; None of the patients with phase I IgG titers<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#58;1024 underwent prolonged antibiotic treatment&#44; and none progressed to endocarditis&#46; This patient group showed no statistically significant differences in terms of age&#44; clinical presentation&#44; abnormal laboratory test results or antibiotic treatment compared with the patients who did not reach phase I IgG antibody titers<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#58;1024 in the first 3 months&#46; The patients with early increases in phase I IgG antibody titers<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#58;1024 presented fever lasting longer than 14 days more frequently &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">TTE was only performed on 12 patients in the entire series and detected degenerative valvular heart disease in only 2 of the patients &#40;both with phase I IgG antibody levels<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#58;1024 in the first 3 months&#41;&#59; the other patients had normal levels&#46; After comparing the patients who did not undergo TTE with those who did&#44; we only found differences in terms of age&#44; with the younger patients not undergoing TTE &#40;median age&#44; 41 years &#91;IQR&#44; 29&#8211;47&#93; vs&#46; 48 &#91;IQR&#44; 43&#8211;57&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;03&#41;&#44; with no significant differences in the other analyzed variables &#40;sex&#44; clinical presentation&#44; fever duration&#44; abnormal laboratory test results and early increase in phase I IgG antibody levels&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Only 35 patients &#40;44&#37;&#41; underwent antibiotic treatment &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In particular&#44; the patients whose symptoms had subsided by the time the serological results were available did not undergo antibiotherapy&#46; The 35 treated patients showed no statistically significant differences compared with the 45 untreated patients in terms of age&#44; sex&#44; susceptibility to chronicity&#44; clinical presentation&#44; fever duration and transaminase levels&#46; The treated patients had a significantly higher rate of serum C-reactive protein levels &#62;10<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;27&#47;35 &#91;77&#37;&#93; vs&#46; 15&#47;45 &#91;33&#37;&#93;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Two patients underwent extended antibiotherapy&#44; and both patients were treated with doxycycline and hydroxychloroquine&#46; The first patient&#44; who had no prior valvular heart disease&#44; underwent antibiotherapy starting on the fifth month of follow-up due to phase I IgG antibody levels<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#58;1024&#59; the treatment was maintained for 12 months&#46; The second&#44; who had prior mitral valvular disease&#44; underwent antibiotherapy starting the third month due to phase I IgG antibody levels of 1&#58;4086&#59; follow-up was lost 4 months later&#46; The 2 patients had been treated during the acute phase and subsequently remained asymptomatic&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">None of the patients in the series developed endocarditis over the course of the follow-up&#44; which lasted a median of 100 months &#40;IQR&#44; 76&#8211;136&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Raoult et al&#46; observed that 100&#37; of patients with acute Q fever who also had any type of valvular heart disease &#40;detected by TTE or TEE&#41;&#44; developed endocarditis in the following 2 months&#44; unless prolonged antibiotherapy &#40;for a year&#41; with doxycycline and hydroxychloroquine was administered&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> In this series&#44; 7&#47;72 included cases of acute Q fever showed early antibody titers<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#58;800&#46; Some form of valvular heart disease was detected in all of these patients&#44; detected by TEE in the majority of cases&#46; Systematic echocardiography and serial serologic testing was therefore recommended&#44; especially for older patients&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">After an outbreak of Q fever in The Netherlands in 2007&#44; several studies were published that showed significant differences with respect to the previously mentioned recommendations for preventing endocarditis by <span class="elsevierStyleItalic">C&#46; burnetii</span>&#46; Van der Hoek et al&#46; found a low rate of progression to endocarditis &#40;3&#47;686 cases&#44; 0&#46;5&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> even when the patients presented prior degenerative valvular heart disease<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> or phase I IgG levels<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#58;800 during the first 3 months of evolution&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> Another publication defined a history of previous valve surgery&#44; vascular prosthesis&#44; aneurysms&#44; renal failure and an age over 60 years as risk factors for developing chronic <span class="elsevierStyleItalic">C&#46; burnetii</span> infection&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> In light of these results&#44; the authors do not recommend performing TTE for all patients or prolonged treatment based solely on the serological results&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Our data disagree with the findings of Raoult et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> and agree with the observations of other authors&#44; including those of a Spanish series in which there were no cases of progression to endocarditis&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#44;20</span></a> As with these series&#44; our experience has been that the early increase in phase I IgG antibody levels is not associated with a subsequent progression to endocarditis&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#44;18&#44;20</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In our series&#44; only 16&#47;80 &#40;20&#37;&#41; of the patients included in the study presented phase I IgG titers<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#58;1024 during the first 3 months&#46; For all patients in the series&#44; except for 2 cases in which prolonged treatment was administered&#44; the therapy applied was the acute Q fever therapy&#46; However&#44; a number of patients who were asymptomatic by the time the serological results were available were not treated&#46; None of the patients developed endocarditis&#46; It can be argued that the lack of systematic echocardiography detracts from the validity of this finding&#46; However&#44; although 6&#37; of cases of endocarditis by <span class="elsevierStyleItalic">Coxiella</span> can be asymptomatic&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> the lack of clinical data over the course of the highly prolonged progression in our series is surprising&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A number of authors have proposed that phase I IgG antibody titers &#8805;1&#58;6400 should be considered a major criterion of endocarditis and that titers &#60;1&#58;6400 but &#8805;1&#58;800 such be considered a minor criterion&#44; thereby achieving a positive predictive value of 75&#37; for endocarditis&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">13&#44;21</span></a> The definitive diagnosis of endocarditis requires isolates from the surgically removed heart valve &#40;cultures&#44; CRP or immunohistochemistry&#41; or&#44; lacking valve tissue&#44; the presence of clinical symptoms compatible with chronic infection&#47;valve dysfunction along with other major or minor clinical criteria&#46; According to other authors&#44; the diagnosis of chronic Q fever should be based on clinical data&#44; due to the observed variability in the serologic values and results of the CRP technique&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> although they consider that chronic Q fever is proven when there is a positive CRP result in blood or tissue after surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> None of our patients showed phase I IgG antibody titers &#8805;1&#58;6400 over time or symptoms suggestive of chronicity&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In the previously mentioned series&#44; the development of endocarditis was correlated with age &#40;mean of 66 years in the Dutch group and older than 40 years in the French group&#41;&#46; The factors that could justify the non-progression to endocarditis in our patients include the fact that these were young individuals in whom the prevalence of prior valvular heart disease was low&#44; given that this prevalence is estimated at 0&#46;7&#37; in patients younger than 54 years&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a> Surprisingly&#44; in the French study&#44; the prevalence of valvular heart disease at this age reached 45&#37;&#46; It is possible that the differences observed between the various studies could be due to selection biases according to the type of center and study population and to differences in the circulating strains in each area&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Our study&#39;s limitations include its retrospective character&#44; the fact that it was conducted in a single center and the lack of a pre-established protocol for the care of these patients&#46; Many of our patients did not therefore undergo extended serologic follow-up or echocardiographic studies&#46; Thus&#44; cases of subclinical endocarditis might have gone undiagnosed&#46; However&#44; none of the patients were carriers of valvular or vascular prosthesis or required valve surgery over the course of their evolution&#46; Moreover&#44; CRP tests in blood were not conducted for all patients&#44; which could have detected cases of asymptomatic chronic Q fever &#40;estimated sensitivity of 33&#8211;64&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Based on our results&#44; it appears that the detection in asymptomatic patients of phase I IgG antibody levels &#8805;1&#58;1024 in the first 3 months after an episode of acute Q fever&#44; even when prolonged antibiotherapy is not provided&#44; is not associated with progression to endocarditis&#46; The diagnostic&#8211;therapeutic approach after an episode of acute Q fever should be based mainly on the established risk factors or the presence of clinical symptoms&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:10 [
        0 => array:3 [
          "identificador" => "xres519455"
          "titulo" => "Abstract"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "abst0005"
              "titulo" => "Objectives"
            ]
            1 => array:2 [
              "identificador" => "abst0010"
              "titulo" => "Patients and methods"
            ]
            2 => array:2 [
              "identificador" => "abst0015"
              "titulo" => "Results"
            ]
            3 => array:2 [
              "identificador" => "abst0020"
              "titulo" => "Conclusions"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec539980"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres519456"
          "titulo" => "Resumen"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "abst0025"
              "titulo" => "Objetivo"
            ]
            1 => array:2 [
              "identificador" => "abst0030"
              "titulo" => "Pacientes y m&#233;todos"
            ]
            2 => array:2 [
              "identificador" => "abst0035"
              "titulo" => "Resultados"
            ]
            3 => array:2 [
              "identificador" => "abst0040"
              "titulo" => "Conclusiones"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec539979"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Background"
        ]
        5 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Patients and methods"
        ]
        6 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Results"
        ]
        7 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Conflicts of interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-11-09"
    "fechaAceptado" => "2015-01-16"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec539980"
          "palabras" => array:6 [
            0 => "Q fever"
            1 => "<span class="elsevierStyleItalic">Coxiella burnetii</span>"
            2 => "Endocarditis"
            3 => "Serology"
            4 => "Echocardiogram"
            5 => "Prevention"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec539979"
          "palabras" => array:6 [
            0 => "Fiebre Q"
            1 => "<span class="elsevierStyleItalic">Coxiella burnetii</span>"
            2 => "Endocarditis"
            3 => "Serolog&#237;a"
            4 => "Ecocardiograma"
            5 => "Prevenci&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Assess clinical and serological data as parameters indicative of a possible evolution to endocarditis after an episode of acute Q fever&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective cohort study of evolution to endocarditis after an acute Q fever episode&#44; analyzing the clinical and serological evolution and the antibiotic treatment administered&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Eighty patients were recruited&#44; 20&#37; of whom had phase I IgG antibody levels<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#58;1024 in the first 3 months&#46; Only 44&#37; of the patients underwent antibiotherapy in the acute phase&#59; only 2 patients underwent extended antibiotherapy&#46; Fifteen percent of the patients underwent an echocardiogram&#46; None of the patients had symptoms suggestive of chronic infection or progressed to endocarditis after a median follow-up of 100 months&#44; regardless of the early increase in phase <span class="elsevierStyleSmallCaps">I</span> IgG antibodies&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The early increase in phase <span class="elsevierStyleSmallCaps">I</span> IgG antibodies in asymptomatic patients is not associated with progression to endocarditis despite not undergoing prolonged antibiotic treatment&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Valorar los datos cl&#237;nicos y serol&#243;gicos como par&#225;metros indicativos de posible evoluci&#243;n a endocarditis tras un episodio de fiebre Q aguda&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohortes retrospectivo de la evoluci&#243;n a endocarditis tras un episodio de fiebre Q aguda&#44; analizando evoluci&#243;n cl&#237;nica&#44; serol&#243;gica y tratamiento antibi&#243;tico recibido&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se reclut&#243; a 80 pacientes&#44; presentando el 20&#37; niveles de anticuerpos IgG de fase <span class="elsevierStyleSmallCaps">i</span> &#8805; 1&#58;1&#46;024 en los primeros 3 meses&#46; Solo el 44&#37; recibi&#243; antibioterapia en la fase aguda&#59; &#250;nicamente 2 enfermos recibieron antibioterapia prolongada&#46; Se realiz&#243; ecocardiograma al 15&#37;&#46; Ning&#250;n paciente present&#243; s&#237;ntomas indicativos de infecci&#243;n cr&#243;nica ni evolucion&#243; a endocarditis tras una mediana de seguimiento de 100 meses&#44; independientemente de la elevaci&#243;n precoz de anticuerpos IgG de fase <span class="elsevierStyleSmallCaps">i&#46;</span></p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La elevaci&#243;n precoz de anticuerpos IgG fase <span class="elsevierStyleSmallCaps">i</span> no se asoci&#243; a evoluci&#243;n a endocarditis a pesar de no haberse realizado tratamiento antibi&#243;tico prolongado en pacientes asintom&#225;ticos&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Pacientes y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mart&#237;n-Aspas A&#44; Collado-P&#233;rez C&#44; Vela-Manzano L&#44; Fern&#225;ndez-Guti&#233;rrez del &#193;lamo C&#44; Tinoco-Racero I&#44; Gir&#243;n-Gonz&#225;lez JA&#46; Fiebre Q aguda&#58; riesgo de desarrollo de endocarditis&#46; Rev Clin Esp&#46; 2015&#59;215&#58;265&#8211;271&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; ALT&#44; alanine amino transaminase&#59; AST&#44; aspartate amino transaminase&#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=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Age&#44; years &#40;interquartile range&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;30&#8211;51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Male sex&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Urban residence&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69 &#40;86&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Temperature</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;38</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#176;C&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78 &#40;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Fever duration&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#60;7 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7&#8211;14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Clinical presentation&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypertransaminasemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unexplained fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Chronic asthenia up to 6 months later&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Immunosuppression&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Platelet count</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">150&#44;000&#47;&#956;l&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">AST</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;120 U&#47;L&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">ALT</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;120 U&#47;L&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43 &#40;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Chest radiography conducted&#47;pathological&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31 &#40;39&#41;&#47;6 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">C-reactive protein</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;10</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mg&#47;dL&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Abdominal ultrasound performed&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hepatomegaly&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Splenomegaly&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Transthoracic echocardiography performed&#47;pathological&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;15&#41;&#47;2 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Treated with doxycycline&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Duration in days&#44; <span class="elsevierStyleItalic">n</span> &#40;interquartile range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;14&#8211;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Treated with ciprofloxacin&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Duration in days&#44; <span class="elsevierStyleItalic">n</span> &#40;interquartile range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;14&#8211;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Patients with combined treatment&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab838199.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Epidemiological&#44; clinical and laboratory data on the 80 patients with acute Q fever included in this study&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; CIP&#44; doxycycline&#59; DXC&#44; doxycycline&#59; HCL&#44; hydroxychloroquine&#59; NA&#44; not available&#59; NP&#44; not performed&#59; susceptibility to chronicity&#44; presence of valvular heart disease or immunosuppression&#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="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&#44; years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Delay in initial serology&#44; weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Susceptibility to chronicity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Echocardiogram&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum phase I&#47;II IgG in first 3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Final phase I&#47;II IgG &#40;difference in weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up&#44; months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiotic therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1024&#47;1024&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">118&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DXC 21 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1024&#47;4096&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">512&#47;512 &#40;112&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DXC 21 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aortic valve disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4096&#47;8192&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1024&#47;2048 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DXC 14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1024&#47;1024&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">147&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4096&#47;4096&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1024&#47;2048 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">148&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DXC 14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1024&#47;4096&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2048&#47;2048&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">112&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2048&#47;8192&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DXC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CIP 14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4096&#47;8192&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1024&#47;4096 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">141&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1024&#47;1024&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2048&#47;2048&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">158&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DXC 14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1024&#47;1024&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1024&#47;4096 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DXC 21 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mitral valve disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4086&#47;8172&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">512&#47;512 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DXC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>HCL 3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8192&#47;8192&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">256&#47;512 &#40;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DXC 14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1024&#47;2048&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">512&#47;256 &#40;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">136&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8192&#47;16&#44;384&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4096&#47;8192 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">152&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab838201.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Patients with phase I IgG values &#8805;1&#58;1024 in the first 3 months of acute Q fever&#58; serological evolution and prescribed antibiotherapy&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; ALT&#44; alanine amino transaminase&#59; AST&#44; aspartate amino transaminase&#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="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Increase in phase 1 IgG antibody levels &#40;&#62; 1&#58;1024&#41; in the first 3 months</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No &#40;64 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes &#40;16 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Median age&#44; years &#40;interquartile range&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;29&#8211;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44 &#40;32&#8211;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;582&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Male sex&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46 &#40;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;333&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Clinical presentation&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypertransaminasemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38 &#40;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;386&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unexplained fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;364&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Fever duration&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#60;7 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;069&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7&#8211;14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;866&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Increased transaminase levels&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>AST<span class="elsevierStyleHsp" style=""></span>&#62;120<span class="elsevierStyleHsp" style=""></span>U&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;278&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ALT<span class="elsevierStyleHsp" style=""></span>&#62;120<span class="elsevierStyleHsp" style=""></span>U&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;537&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Platelet count &#60;150&#44;000&#47;&#956;L&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;695&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">C-reactive protein &#62;10</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mg&#47;dL&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;955&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Treatment with doxycycline&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;281&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab838200.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Differences in the epidemiological&#44; clinical and laboratory variables between the patients with and without an increase in phase I IgG antibodies &#8805;1&#58;1024 in the first 3 months&#46;</p>"
        ]
      ]
      3 => array:5 [
        "identificador" => "tb0005"
        "tipo" => "MULTIMEDIATEXTO"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "texto" => array:1 [
          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">What we know&#63;</span><p id="par0005" class="elsevierStylePara elsevierViewall">Endocarditis and endovascular infections develop after an episode of acute Q fever in 0&#37; and 1&#46;5&#37; of cases&#46; The presence of prior valvular heart disease constitutes the main risk factor&#46; There has therefore been debate about the advisability of performing transthoracic echocardiography &#40;TTE&#41; for all patients with acute Q fever and&#44; in the event that valvular heart disease is detected&#44; starting treatment with doxycycline plus hydroxychloroquine for a year&#46; This study evaluates the progression to endocarditis and the prognostic value of serology for a cohort of patients with acute Q fever&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">What this article provides&#63;</span><p id="par0010" class="elsevierStylePara elsevierViewall">None of the 80 patients with acute Q fever included in this study progressed to endocarditis&#46; The early increase in the levels of phase 1 antibodies against <span class="elsevierStyleItalic">Coxiella burnetti</span> had no prognostic value&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Editors</p></span></span>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:23 [
            0 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Natural history and pathophysiology of Q fever"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46; Raoult"
                            1 => "T&#46; Marrie"
                            2 => "J&#46; Mege"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(05)70052-9"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2005"
                        "volumen" => "5"
                        "paginaInicial" => "219"
                        "paginaFinal" => "226"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15792739"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "<span class="elsevierStyleItalic">Coxiella burnetii</span> genotyping"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "O&#46; Glazunova"
                            1 => "V&#46; Roux"
                            2 => "O&#46; Freylikman"
                            3 => "Z&#46; Sekeyova"
                            4 => "G&#46; Fournous"
                            5 => "J&#46; Tyczka"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3201/eid1108.041354"
                      "Revista" => array:6 [
                        "tituloSerie" => "Emerg Infect Dis"
                        "fecha" => "2005"
                        "volumen" => "11"
                        "paginaInicial" => "1211"
                        "paginaFinal" => "1217"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16102309"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Q fever&#58; epidemiology&#44; clinical features and prognosis&#46; A study from 1983 to 1999 in the South of Spain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; De Alarc&#243;n"
                            1 => "J&#46;L&#46; Villanueva"
                            2 => "P&#46; Viciana"
                            3 => "L&#46; L&#243;pez-Cort&#233;s"
                            4 => "R&#46; Torronteras"
                            5 => "M&#46; Bernabeu"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Infect"
                        "fecha" => "2003"
                        "volumen" => "47"
                        "paginaInicial" => "110"
                        "paginaFinal" => "116"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12860143"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Endocarditis por fiebre Q en Espa&#241;a&#46; Caracter&#237;sticas cl&#237;nicas y evoluci&#243;n"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;V&#46; Mogoll&#243;n"
                            1 => "M&#46;P&#46; Anguita"
                            2 => "J&#46;M&#46; Aguado"
                            3 => "P&#46; Tornos"
                            4 => "J&#46;M&#46; Mir&#243;"
                            5 => "J&#46; G&#225;lvez-Acebal"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.eimc.2010.07.015"
                      "Revista" => array:6 [
                        "tituloSerie" => "Enferm Infecc Microbiol Clin"
                        "fecha" => "2011"
                        "volumen" => "29"
                        "paginaInicial" => "109"
                        "paginaFinal" => "116"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21333397"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Long-term outcome of Q fever endocarditis&#58; a 26-year personal survey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; Million"
                            1 => "F&#46; Thuny"
                            2 => "H&#46; Richet"
                            3 => "D&#46; Raoult"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(10)70135-3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2010"
                        "volumen" => "10"
                        "paginaInicial" => "527"
                        "paginaFinal" => "535"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20637694"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Q fever 1985&#8211;1998&#46; Clinical and epidemiologic features of 1383 infections"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Raoult"
                            1 => "H&#46; Tissot-Dupont"
                            2 => "C&#46; Foucault"
                            3 => "J&#46; Gouvernet"
                            4 => "P&#46;E&#46; Forunier"
                            5 => "E&#46; Bernit"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Medicine &#40;Baltimore&#41;"
                        "fecha" => "2000"
                        "volumen" => "79"
                        "paginaInicial" => "109"
                        "paginaFinal" => "123"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chronic Q fever in the Netherlands 5 years after the start of the Q fever epidemic&#58; results from the Dutch Chronic Q fever database"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46;M&#46; Kampschreur"
                            1 => "C&#46;E&#46; Delsing"
                            2 => "R&#46;H&#46; Groenwold"
                            3 => "M&#46;C&#46; Wegdam-Blas"
                            4 => "C&#46;P&#46; Bleeker-Rovers"
                            5 => "M&#46;G&#46; de Jager-Leclercq"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1128/JCM.03221-13"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Microbiol"
                        "fecha" => "2014"
                        "volumen" => "52"
                        "paginaInicial" => "1637"
                        "paginaFinal" => "1643"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24599987"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Gipuzkoa&#44; Basque Country&#44; Spain &#40;1984&#8211;2004&#41;&#58; a hyperendemic area of Q fever"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Montes"
                            1 => "G&#46; Cilla"
                            2 => "D&#46; Vicente"
                            3 => "V&#46; Nieto"
                            4 => "M&#46; Ercibengoa"
                            5 => "E&#46; Perez-Trallero"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1196/annals.1374.020"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann N Y Acad Sci"
                        "fecha" => "2006"
                        "volumen" => "1078"
                        "paginaInicial" => "129"
                        "paginaFinal" => "132"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17114693"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of Q fever endocarditis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "G&#46;J&#46; Limonard"
                            1 => "M&#46;H&#46; Nabuurs-Franssen"
                            2 => "P&#46;N&#46; Dekhuijzen"
                            3 => "C&#46;A&#46; Groot"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(11)70016-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "11"
                        "paginaInicial" => "82"
                        "paginaFinal" => "83"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21272791"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risks factors and prevention of Q fever endocarditis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "F&#46; Fenollar"
                            1 => "P&#46;E&#46; Fournier"
                            2 => "M&#46;P&#46; Carrieri"
                            3 => "G&#46; Habib"
                            4 => "T&#46; Messana"
                            5 => "D&#46; Raoult"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/321889"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2001"
                        "volumen" => "33"
                        "paginaInicial" => "312"
                        "paginaFinal" => "316"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11438895"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Endocarditis after acute Q fever in patients with previously undiagnosed valvulopathies"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "F&#46; Fenollar"
                            1 => "F&#46; Thuny"
                            2 => "B&#46; Xeridat"
                            3 => "H&#46; Lepidi"
                            4 => "D&#46; Raoult"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/500402"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2006"
                        "volumen" => "42"
                        "paginaInicial" => "818"
                        "paginaFinal" => "821"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16477559"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "From acute Q fever to endocarditis&#58; serological follow-up strategy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "C&#46; Landais"
                            1 => "F&#46; Fenollar"
                            2 => "F&#46; Thuny"
                            3 => "D&#46; Raoult"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/515401"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2007"
                        "volumen" => "44"
                        "paginaInicial" => "1337"
                        "paginaFinal" => "1340"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17443471"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chronic Q fever&#58; expert opinion versus literature analysis and consensus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "D&#46; Raoult"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jinf.2012.04.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Infect"
                        "fecha" => "2012"
                        "volumen" => "65"
                        "paginaInicial" => "102"
                        "paginaFinal" => "108"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22537659"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reduction in incidence of Q fever endocarditis&#58; 27 years of experience of a national reference center"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46; Edouard"
                            1 => "M&#46; Million"
                            2 => "G&#46; Royer"
                            3 => "R&#46; Giorgi"
                            4 => "D&#46; Grisoli"
                            5 => "D&#46; Raoult"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jinf.2013.10.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Infect"
                        "fecha" => "2014"
                        "volumen" => "68"
                        "paginaInicial" => "141"
                        "paginaFinal" => "148"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24183890"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "One-year follow-up of patients of the ongoing Dutch Q fever outbreak&#58; clinical&#44; serological and echocardiographic findings"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46;J&#46; Limonard"
                            1 => "M&#46;H&#46; Nabuurs-Franssen"
                            2 => "G&#46; Weers-Pothoff"
                            3 => "C&#46; Wijkmans"
                            4 => "R&#46; Besselink"
                            5 => "A&#46;M&#46; Horrevorts"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s15010-010-0052-x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Infection"
                        "fecha" => "2010"
                        "volumen" => "38"
                        "paginaInicial" => "471"
                        "paginaFinal" => "477"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20857313"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;S&#46; Li"
                            1 => "D&#46;J&#46; Sexton"
                            2 => "N&#46; Mick"
                            3 => "R&#46; Nettles"
                            4 => "V&#46;G&#46; Fowler Jr&#46;"
                            5 => "T&#46; Ryan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/313753"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2000"
                        "volumen" => "30"
                        "paginaInicial" => "633"
                        "paginaFinal" => "638"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10770721"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evolution from acute Q fever to endocarditis is associated with underlying valvulopathy and age and can be prevented by prolonged antibiotic treatment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Million"
                            1 => "G&#46; Walter"
                            2 => "F&#46; Thuny"
                            3 => "G&#46; Habib"
                            4 => "D&#46; Raoult"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/cid/cit419"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2013"
                        "volumen" => "57"
                        "paginaInicial" => "836"
                        "paginaFinal" => "844"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23794723"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Follow-up of 686 patients with acute Q fever and detection of chronic infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "W&#46; Van der Hoek"
                            1 => "B&#46; Versteeg"
                            2 => "J&#46; Meekelenkamp"
                            3 => "N&#46; Renders"
                            4 => "A&#46; Leenders"
                            5 => "I&#46; Weers-Pothoff"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/cid/cir234"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "52"
                        "paginaInicial" => "1431"
                        "paginaFinal" => "1436"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21628483"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Identification of risk factors for chronic Q fever&#44; the Netherlands"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46;M&#46; Kampschreur"
                            1 => "S&#46; Dekker"
                            2 => "J&#46; Hagenaars"
                            3 => "P&#46; Lestrade"
                            4 => "N&#46; Renders"
                            5 => "M&#46; de Jager-Leclercq"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3201/eid1804.111478"
                      "Revista" => array:6 [
                        "tituloSerie" => "Emerg Infect Dis"
                        "fecha" => "2012"
                        "volumen" => "18"
                        "paginaInicial" => "563"
                        "paginaFinal" => "570"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22469535"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Serologic assessment of the risk of developing chronic Q fever in cohorts of acutely infected individuals"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;N&#46; Hung"
                            1 => "L&#46;J&#46; Lin"
                            2 => "M&#46;Y&#46; Hou"
                            3 => "P&#46;S&#46; Lin"
                            4 => "Y&#46;C&#46; Wang"
                            5 => "P&#46;Y&#46; Shu"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jinf.2010.10.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Infect"
                        "fecha" => "2011"
                        "volumen" => "62"
                        "paginaInicial" => "39"
                        "paginaFinal" => "44"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21034771"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ongoing queries&#58; interpretation of serology in asymptomatic or atypical chronic Q fever"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "T&#46; De Silva"
                            1 => "A&#46; Chapman"
                            2 => "G&#46; Kudesia"
                            3 => "M&#46; McKendrick"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jinf.2005.07.024"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Infect"
                        "fecha" => "2006"
                        "volumen" => "52"
                        "paginaInicial" => "e113"
                        "paginaFinal" => "e116"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16126277"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Burden of valvular heart diseases&#58; a population-based study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "V&#46;T&#46; Nkomo"
                            1 => "J&#46;M&#46; Gardin"
                            2 => "T&#46;N&#46; Skelton"
                            3 => "J&#46;S&#46; Gottdiener"
                            4 => "C&#46;G&#46; Scott"
                            5 => "M&#46; Enriquez-Sarano"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(06)69208-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2006"
                        "volumen" => "368"
                        "paginaInicial" => "1005"
                        "paginaFinal" => "1011"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16980116"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnosis and management of Q fever &#8211; United States&#44; 2013&#58; recommendations from CDC and the Q fever working group"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Anderson"
                            1 => "H&#46; Bijlmer"
                            2 => "P&#46;E&#46; Fournier"
                            3 => "S&#46; Graves"
                            4 => "J&#46; Hartzell"
                            5 => "G&#46;J&#46; Kersh"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "MMWR Recomm Rep"
                        "fecha" => "2013"
                        "volumen" => "62"
                        "paginaInicial" => "1"
                        "paginaFinal" => "30"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24352112"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/22548874/0000021500000005/v1_201506010556/S2254887415000387/v1_201506010556/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "1903"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Brief Original"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021500000005/v1_201506010556/S2254887415000387/v1_201506010556/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887415000387?idApp=WRCEE"
]

Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2015.01.003

The statistics are updated each day

Year/Month	Html	Pdf	Total

2023 March	9	3	12
2018 February	4	0	4
2018 January	12	0	12
2017 December	6	0	6
2017 November	13	0	13
2017 October	8	0	8
2017 September	11	0	11
2017 August	2	0	2
2017 July	12	0	12
2017 June	7	0	7
2015 June	0	1	1
2015 April	0	2	2

Indexed in:

Follow us:

Subscribe:

Statistics

Indexed in:

Follow us:

Subscribe:

Statistics

Subscribe to our newsletter