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        "titulo" => "Prevalencia y caracter&#237;sticas de la anemia en personas con diabetes mellitus de 50 a&#241;os o m&#225;s en un &#225;rea sanitaria de C&#225;diz &#40;Espa&#241;a&#41;"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Prevalence of anemia&#46; A&#41; In the general population &#40;95&#37; CI 28&#46;7&#37;&#8211;31&#46;1&#37;&#41;&#46; B&#41; Stratified by sex&#58; in women &#40;95&#37; CI 31&#46;5&#37;&#8211;35&#46;1&#37;&#41; and in men &#40;95&#37; CI 25&#46;2&#37;&#8211;28&#46;3&#37;&#41;&#46; C&#41; Stratified by sex and age group&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Diabetes mellitus &#40;DM&#41; is a chronic metabolic disease whose prevalence is growing at an alarming rate worldwide&#46; In 2021&#44; it was estimated that approximately 529 million people worldwide had DM&#44; a prevalence of 6&#46;1&#37; &#40;95&#37; CI 5&#46;8&#37;&#8211;6&#46;5&#37;&#41;&#46; In older adults&#44; this prevalence mainly reflects type 2 DM &#40;96&#37; of cases in 2021&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; in the study area&#44; the prevalence as detected by drug use is actually higher&#58; 9&#46;07&#37; &#40;95&#37; CI&#58; 9&#46;01&#37;&#8211;9&#46;13&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Anemia&#44; another significant health problem&#44; affects people of all ages&#46; Its overall global prevalence was 22&#46;8&#37; &#40;95&#37; CI&#58; 22&#46;6&#37;&#8211;23&#46;1&#37;&#41;&#46; In addition&#44; it was responsible for 58&#46;6 million years lived with disability worldwide in 2021&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Anemia is often considered to be a condition that mainly affects children and women of reproductive age&#44; with iron deficiency being the most common cause&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; its prevalence is also high in older adults<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and a greater presence of other etiologies is observed&#58; anemia of chronic disease&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> anemia of renal disease&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> multifactorial anemia&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and even cases of &#8220;unexplained anemia&#46;&#8221;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The coexistence of anemia and DM has become a significant public health problem&#44; especially in older adult patients&#46; Anemia is often underestimated as a comorbidity of diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> For example&#44; despite being well known that it is up to twice as likely to be present in patients with DM&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> anemia is hardly mentioned in the ADA Standards of Care&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Estimates of its prevalence vary widely depending on the population and region studied&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Moreover&#44; it is critically important to add two additional factors to this epidemiological equation&#58; old age and the presence of chronic kidney disease &#40;CKD&#41;&#46; Anemia is more prevalent in older adult patients<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7</span></a> and its frequency increases significantly with renal impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In patients with DM&#44; red blood cell abnormalities and anemia have been associated with an increased risk of microvascular complications&#44; wound healing impairment&#44; and&#47;or macrovascular disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> Taken together&#44; all this translates into a marked increase in all-cause mortality &#40;HR&#8239;&#61;&#8239;3&#46;41 &#40;2&#46;75&#8211;4&#46;23&#41;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In a worldwide systematic review&#44; Arkew et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> describe a prevalence of anemia in adult patients with DM of about 27&#37; &#40;95&#37; CI&#58; 24&#37;&#8211;31&#37;&#41;&#46; It should be noted that it includes only one European study&#44; which was conducted in France by Bri&#232;re et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and which described a prevalence of 25&#46;7&#37;&#44; a greater impact on women&#44; and a direct relationship with disease duration&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the United States of America&#44; a prevalence of 13&#46;5&#37; has been described&#44; a figure that increases to 20&#37; in adults with DM and CKD&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In Australia&#44; it was 11&#46;5&#37; &#40;95&#37; CI&#58; 10&#46;0&#37;&#8211;13&#46;2&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#59; in the Middle East&#44; 28&#46;5&#37; &#40;95&#37; CI&#58; 26&#46;3&#37;&#8211;30&#46;8&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#59; in Africa&#44; 35&#37; &#40;95&#37; CI&#58; 28&#37;&#8211;42&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#59; and in the Far East&#44; 45&#37; &#40;95&#37; CI&#58; 37&#37;&#8211;54&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> In Spain&#44; the prevalence and precise characterization of anemia among individuals with DM is unknown&#46; Even in the general population&#44; knowledge is scarce and disparate&#44; with estimates ranging from 3&#46;78&#37; described in Barcelona<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> to 8&#46;99&#37; &#40;men&#58; 7&#46;8&#37; vs women&#58; 10&#37;&#41; in Huesca&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The main objective of this study is to determine the prevalence and characterize anemia in a population with DM in southern Spain as well as to describe its relationship with CKD and diabetes control&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design</span><p id="par0045" class="elsevierStylePara elsevierViewall">A retrospective&#44; descriptive&#44; cross-sectional study was conducted using electronic data from patients who&#58; I&#41; had any type of DM&#59; II&#41; were aged &#8805;50 years&#59; and III&#41; had undergone outpatient analytical determinations that included a complete blood count between November 2019 and March 2022 in the Campo de Gibraltar Este Healthcare Area&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">After approval by the Research Ethics Committee of C&#225;diz&#44; the records of the State of Diabetes in the Campo de Gibraltar Este Healthcare Area &#40;SIDICAM&#44; for its initials in Spanish&#41; database &#40;DB&#41; were used&#46; Pseudonymized data obtained during the routine clinical care of public health system users were collected&#46; These data include demographic information&#44; laboratory tests&#44; and medications used&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The laboratory parameters analyzed included fasting blood glucose &#40;FBG&#41;&#44; HbA1c&#44; estimated glomerular filtration rate &#40;eGFR&#41; calculated according to CKD-EPI-2009 &#40;Chronic Kidney Disease Epidemiology Collaboration&#41;&#44; and morning urine albumin-creatinine ratio &#40;ACR&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In addition&#44; the data included a complete blood count that included hemoglobin &#40;Hb&#41;&#44; hematocrit&#44; and basic blood count data &#40;mean corpuscular volume &#40;MCV&#41; and mean corpuscular hemoglobin concentration &#40;MCHC&#41;&#41;&#46; The entire healthcare area is located less than 200&#8239;m above sea level&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The population aged &#8805;50 years was chosen for three reasons&#58; to rule out&#44; to the extent possible&#44; the direct influence of menstruation and of pregnancy in the female population<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and because most of the population with DM is concentrated in this age group&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The characteristics of the time of anemia diagnosis will be described&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Definitions</span><p id="par0065" class="elsevierStylePara elsevierViewall">The World Health Organization &#40;WHO&#41; defines anemia in the adult and older adult population as a concentration of Hb&#8239;&#60;&#8239;12&#8239;g&#47;dL for non-pregnant women and Hb&#8239;&#60;&#8239;13&#8239;g&#47;dL for men&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Anemia was classified according to clinical severity and red blood cell morphology as described below&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Clinical classification based on Hb level&#58; mild &#40;female&#58; 11&#8211;11&#46;9&#8239;g&#47;dL&#59; male&#58; 11&#8211;12&#46;9&#8239;g&#47;dL&#41;&#44; moderate &#40;8&#8211;10&#46;9&#8239;g&#47;dL&#41;&#44; or severe &#40;&#60;8&#8239;g&#47;dL&#41;&#46; Classification based on MCV&#58; microcytic &#40;MCV&#8239;&#60;&#8239;80&#8239;fL&#59; normocytic &#40;MCV 80&#8211;100&#8239;fL&#41;&#44; or macrocytic &#40;MCV&#8239;&#62;&#8239;100&#8239;fL&#41;&#46; Combined morphology classification &#40;MCV and MCHC&#41;&#58; Microcytic-hypochromic &#40;MCV&#8239;&#60;&#8239;80&#8239;fL and MCHC&#8239;&#60;&#8239;32&#8239;pg&#41;&#59; normocytic-hypochromic &#40;MCV 80&#8211;100&#8239;fL and MCHC&#8239;&#60;&#8239;32&#8239;pg&#41;&#44; normocytic-normochromic &#40;MCV 80&#8211;100&#8239;fL and MCHC&#8239;&#8805;&#8239;32&#8239;pg&#41;&#44; or macrocytic &#40;MCV&#8239;&#62;&#8239;100&#8239;fL&#41;&#46; Iron deficiency was defined as absolute &#40;ferritin&#8239;&#60;&#8239;30&#8239;ng&#47;ml&#41; or functional &#40;ferritin&#8239;&#62;&#8239;30 with TSI&#8239;&#60;&#8239;20&#37;&#41;&#44; vitamin B12 &#40;&#60;200&#8239;ng&#47;dL&#41;&#44; and folic acid &#40;&#60;2&#8239;ng&#47;ml&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">DM was defined as HbA1c &#8805;6&#46;5&#37; or if the subject was taking drugs from the ATC-A10 group &#40;DM drugs&#41;&#46; Age was stratified by decade from D5 &#40;5th decade&#41; to D9 &#40;which includes patients &#62;90 years&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">CKD was defined as eGFR&#8239;&#60;&#8239;60&#8239;ml&#47;min&#47;1&#46;73&#8239;m<span class="elsevierStyleSup">2</span> and&#47;or a urinary ACR&#8239;&#62;&#8239;30&#8239;mg&#47;gr&#44; according to the recommendations of national guidelines<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> and the Kidney Disease Improving Global Outcomes &#40;KDIGO-2012&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> After estimating eGFR according to CKD-EPI-09&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> the modified KDIGO-2012 classification was used<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> with two sub-categories for G2&#46; It includes seven categories&#58; G1 &#40;&#8805;90&#41;&#44; G2a &#40;75&#8211;89&#41;&#44; G2b &#40;60&#8211;74&#41;&#44; G3a &#40;45&#8211;59&#41;&#44; G3b &#40;30&#8211;44&#41;&#44; G4 &#40;15&#8211;29&#41;&#44; and G5 &#40;&#60;15&#8239;ml&#47;min&#47;1&#46;73&#8239;m<span class="elsevierStyleSup">2</span>&#41;&#46; Albuminuria was classified as mild &#40;ACR&#8239;&#60;&#8239;30&#59; A1&#41;&#44; moderate &#40;ACR 30&#8211;300&#59; A2&#41; or severe &#40;ACR&#8239;&#62;&#8239;300&#8239;mg&#47;gr&#59; A3&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">According to the etiological diagnostic algorithms of the International Diabetes Federation &#40;IDF&#41; and the Southeast Asian Region &#40;SEAR&#41;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> regarding microcytic or normocytic anemia&#44; it is advisable to order an iron profile test and&#44; in macrocytic anemia&#44; a vitamin B12 and folic acid study as a first measure&#46; These data were analyzed when they would have been determined in these subgroups&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">Out of a population of 8417 individuals with DM aged &#8805;50 years &#40;49&#37; female&#59; median age 70 years &#40;IQR 61&#8211;78&#41;&#41;&#44; 2517 subjects presented with anemia during the study period&#44; revealing a prevalence of anemia of 29&#46;9&#37; &#40;95&#37;CI 28&#46;7&#37;&#8211;31&#46;1&#37;&#41; &#40;54&#46;6&#37; female&#59; median age 76 years &#40;IQR 69&#8211;83&#41;&#41;&#46; It was more common in women &#40;33&#46;3&#37; vs 26&#46;7&#37;&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;01&#41; and increased with age in both sexes from 12&#37; in D5 to 61&#46;8&#37; in D9 &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;01&#41;&#44; although its predominance shifted to men at older ages &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Characteristics and morphology</span><p id="par0090" class="elsevierStylePara elsevierViewall">In regard to severity&#44; most were mild &#40;66&#46;3&#37;&#41; or&#44; to a lesser extent&#44; moderate &#40;30&#46;7&#37;&#41; or severe &#40;3&#37;&#41;&#46; When stratified by sex&#44; more moderate anemia was found in women &#40;37&#46;4&#37; vs&#46; 22&#46;8&#37;&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;01&#41; with a similar frequency in severe anemia&#46; At older ages&#44; both moderate and severe anemia &#40;23&#46;1&#37; and 2&#46;4&#37; in D5 vs&#46; 37&#46;9&#37; and 6&#46;5&#37; in D9&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;01&#41; increased in both sexes&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In the population studied&#44; anemia was mostly normocytic &#40;77&#46;5&#37;&#41; and&#44; to a much lesser extent&#44; microcytic &#40;12&#46;5&#37;&#41;&#44; although these types of anemia were more present in younger women whereas macrocytic anemia &#40;10&#37;&#41; was more predominant in older men with lower eGFRs&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">On reviewing the combined morphology &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; a tendency toward hypochromia &#40;65&#37;&#41; was found &#40;which was predominant in women &#40;71&#46;3&#37; vs 57&#46;8&#37;&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;01&#41;&#41;&#44; accompanied by microcytosis &#40;12&#46;5&#37;&#41; or&#44; more commonly&#44; normocytosis &#40;52&#46;5&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Diabetes control</span><p id="par0105" class="elsevierStylePara elsevierViewall">No association was demonstrated between diabetes control&#44; as assessed via HbA1c levels &#60;7&#37;&#44; and the presence of anemia in this study&#46; Patients with DM who were above targets did not have a higher prevalence of anemia &#40;24&#46;8&#37; vs 24&#46;4&#37;&#59; NS&#41;&#46; This observation was consistent in both sexes and regardless of the presence of CKD&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Kidney disease</span><p id="par0110" class="elsevierStylePara elsevierViewall">The presence of kidney disease&#44; in all its facets&#44; has a direct relationship with the presence of anemia&#58; both jointly &#40;GFR&#8239;&#60;&#8239;60&#8239;ml&#47;min&#47;1&#46;73&#8239;m<span class="elsevierStyleSup">2</span> and&#47;or ACR&#8239;&#62;&#8239;30&#8239;mg&#47;g &#40;44&#46;9&#37; vs 19&#46;8&#37;&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#62;&#8239;&#46;01&#41;&#41;&#44; and separately&#44; either according to eGFR &#40;51&#46;7&#37; vs 20&#46;1&#37;&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;01&#41; or ACR &#40;37&#46;8&#37; vs 22&#37;&#41;&#46; It also increased with worsening CKD&#44; as can be seen in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Etiology</span><p id="par0115" class="elsevierStylePara elsevierViewall">Only 61&#37; of patients with micro-normocytic anemia and 24&#37; of patients with macrocytic anemia had undergone the recommended diagnostic protocol&#46; The distribution of these results for normo-microcytic anemia with or without CKD is shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A&#46; Of the 131 PDM who had macrocytic anemia and who had had a vitamin B12 determination performed&#44; only 31 subjects &#40;18&#37;&#41; had a value below 200&#8239;pg&#47;ml&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">The presence of iron deficiency&#44; both functional and absolute&#44; as well as vitamin B12 deficiency can be found in the entire morphological spectrum of the complete blood counts analyzed&#44; with or without anemia&#44; although with different prevalences &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B and <a class="elsevierStyleCrossRef" href="#fig0020">4</a>C&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Multiple logistic regression analysis of associated factors</span><p id="par0125" class="elsevierStylePara elsevierViewall">A logistic regression analysis of the possible factors associated with anemia was performed which included the use of the different drug classes used in the treatment of individuals with DM&#44; described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">The results of this study reveal a significantly elevated prevalence of anemia in patients with DM over 50 years of age&#44; with a rate close to 30&#37; of the population&#46; This figure is much higher than what has been reported in Western populations&#46; This observation should raise concerns and important questions about its possible clinical implications and underlying mechanisms&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The best comparator would be the study conducted in France by Bri&#232;re et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> However&#44; it was performed in a hospital setting&#44; with a younger population&#44; and with different diabetes types &#40;secondary or gestational&#41;&#44; although the prevalence was similar &#40;29&#46;6&#37;&#41; when only subjects with type 2 DM were evaluated&#46; The European data far exceed those recently published for the United States<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and Australia&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> although the population studied there was also younger&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The factors potentially associated with this high prevalence in patients with DM could be related to its pathophysiology&#46; DM is characterized by significant fluctuations in blood glucose that can lead to the underproduction or impaired function of erythropoietin<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> or transferrin glycation&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> In addition&#44; the chronic inflammation characteristic of DM contributes to the onset of anemia due to an elevated level of circulating proinflammatory cytokines and advanced glycation end products&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Likewise&#44; hyperglycemia causes red blood cells to develop morphological&#44; enzymatic&#44; and biophysical changes due to a multitude of endogenous factors that predispose them to rapid clearance from circulation&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">There are other contributing factors of great importance&#44; such as age and renal dysfunction&#46; Anemia and DM are very prevalent diseases in older adults&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Moreover&#44; DM is the main cause of CKD and it negatively affects both erythropoietin production and iron homeostasis&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The interrelationships among DM&#44; age&#44; renal disease&#44; and anemia are highly relevant&#59; together&#44; they have been associated with an increased risk of morbidity and mortality and&#44; therefore&#44; could partly explain the worse prognosis of individuals with DM&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> In addition&#44; DM is associated with obesity&#44; among other comorbidities&#44; which increases the risk of anemia&#44; given its abnormal management of iron metabolism&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In summary&#44; the prevalence of anemia increases with age and is generally mild-moderate &#40;97&#37;&#41; and predominantly normocytic &#40;78&#37;&#41; and hypochromic &#40;around 66&#37;&#41;&#46; These characteristics are typical of the so-called &#8220;anemia of inflammation&#8221; or &#8220;anemia of chronic disease&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">After performing a pathophysiological study&#44; which was incomplete as usual in real-life studies&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> a significant presence of iron deficiency was described in both subjects with CKD &#40;around 60&#37;&#41; and without it &#40;around 75&#37;&#41;&#46; The importance of this iron deficiency whether it be functional or absolute&#44; must be noted&#44; regardless of the presence of anemia &#40;around 40&#37; vs&#46; around 66&#37;&#41; and its morphological characteristics&#46; Likewise&#44; vitamin B12 and folic acid deficiency can be observed&#44; which were greater in cases of anemia&#44; and not only in macrocytic anemia&#46; It may be related to the etiology of the anemia itself<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> or to metformin use&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Making this interpretation even more difficult and increasing the etiological multiplicity&#44; there is also the well-known association of the multiple drugs used in standard treatment for DM and anemia&#58; renin-angiotensin system blockers&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> antiplatelet drugs&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> anticoagulants&#44; and metformin&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> There is also the previously described negative effect of the use of gliptins or insulins or the neutral effect of GLP1-ras and the protective effect of SGLT2is&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;40</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">All these results corroborate the complex&#44; multifactorial nature of anemia that occurs in a particularly sensitive population&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">It should be noted that this study has several weaknesses typical of a design based on electronic records&#46; There was no direct access to the medical record and&#44; therefore&#44; it has not been possible to analyze important factors that could explain some of the results obtained&#46; Furthermore&#44; it is a retrospective study with a cut-off time and is focused on a specific geographic area&#44; although the approximation to the expected prevalences supports its validity&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In regard to conclusions&#44; this study reveals a high prevalence of anemia in patients with DM&#8212;the highest described in Europe to date&#8212;and its strong association with renal disease&#46; The need for the following must be highlighted&#58; I&#41; early detection&#59; II&#41; a comprehensive diagnosis of anemia in this population&#59; III&#41; further research to better understand the underlying mechanisms&#59; and IV&#41; the ability to develop effective strategies for its prevention and treatment&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Article information</span><p id="par0185" class="elsevierStylePara elsevierViewall">Partial results from this study were presented as an abstract at the 2nd Annual RedGDPS Conference&#44; Madrid&#44; November 22&#8211;23&#44; 2023 and as a communication at the 22nd European Congress of Internal Medicine &#40;ECIM&#41;&#44; March 2024&#44; Istanbul&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0190" class="elsevierStylePara elsevierViewall">This work was conducted thanks to an unrestricted research grant from the <span class="elsevierStyleGrantSponsor" id="gs0005">RedGDPS Foundation&#58; a &#8220;Jos&#233; Luis Torres&#8221; Research Support Grant</span>&#44; second edition&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The authors would like to thank Dr&#46; Salvador Payan &#40;Hematology Department&#44; Virgen del Roc&#237;o University Hospital&#44; Seville&#41; for authorization to use classifications of his own design&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest related to this publication&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Anemia is a common comorbidity in patients with diabetes mellitus &#40;DM&#41;&#44; particularly in older adults&#46; However&#44; there is a lack of data on the prevalence and the characteristics of anemia in this population in Spain&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To describe the prevalence and the characteristics of anemia in patients with DM aged 50 or older &#40;PDM50&#41; in a healthcare district in the province of C&#225;diz&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A retrospective cross-sectional study was conducted that included outpatient&#8217;s laboratory tests &#40;OLT&#41; performed over 30 months at PDM50&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The prevalence of anemia was 29&#46;9&#37; &#40;95&#37; CI&#58; 28&#46;7&#37;&#8211;31&#46;1&#37;&#41;&#44; predominating in women &#40;33&#46;3&#37; vs 26&#46;7&#37;&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;0&#46;01&#41;&#44; in older people stratified by decades &#40;61&#46;7&#37; in 9th decade vs 12&#37; in 5th decade&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;0&#46;01&#41;&#44; and in those with kidney disease &#40;44&#46;7&#37; vs 28&#37;&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;0&#46;01&#41;&#46; Most cases were mild &#40;68&#46;3&#37;&#41;&#44; normocytic &#40;78&#46;7&#37;&#41;&#44; and hypochromic &#40;52&#37;&#41;&#46; Similarly&#44; moderate-to-severe anemia was more frequent in women &#40;39&#37; vs 23&#37;&#41;&#44; their prevalence increased with age &#40;45&#37; in the 9th decade vs 24&#37; in the 5th decade&#41;&#44; and with the progression of kidney damage&#44; either measured by a decreased glomerular filtration rate &#40;GFR&#41; &#40;49&#37; in G4 vs 25&#37; in G1&#41;&#44; or the presence of albuminuria &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;0&#46;01&#41;&#46; No association was found between DM control&#44; based on glycated hemoglobin &#40;HbA1c&#41;&#44; and anemia in either sex &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;0&#46;887&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">This study describes a high prevalence of anemia in PDM50&#44; particularly in women&#44; in the most advantageous people and in the presence of kidney disease&#44; even in early stages&#44; highlighting the clinical importance of this coexistence&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La anemia es una comorbilidad frecuente en pacientes con diabetes mellitus &#40;DM&#41;&#44; particularmente en adultos mayores&#46; Sin embargo&#44; apenas hay datos sobre la prevalencia y las caracter&#237;sticas de la anemia en esta poblaci&#243;n en Espa&#241;a&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Describir la prevalencia y las caracter&#237;sticas de la anemia en pacientes con DM de 50 a&#241;os o m&#225;s &#40;PDM50&#41; de un &#225;rea sanitaria de la provincia de C&#225;diz&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todos</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio transversal retrospectivo que incluy&#243; las determinaciones ambulatorias &#40;DA&#41; realizadas durante 30 meses a PDM50&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de anemia fue del 29&#44;9&#37; &#40;IC 95&#37;&#58; 28&#44;7&#37;&#8211;31&#44;1&#37;&#41;&#44; predominando en las mujeres &#40;33&#44;3&#37; vs 26&#44;7&#37;&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;0&#44;01&#41;&#44; en las personas mayores estratificadas por d&#233;cadas &#40;D9 61&#44;7&#37; vs D5 12&#37;&#44; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;0&#44;01&#41; y en presencia de enfermedad renal &#40;44&#44;7&#37; vs 28&#37;&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;0&#44;01&#41;&#46; La mayor&#237;a de los casos fueron leves &#40;68&#44;3&#37;&#41;&#44; normoc&#237;ticas &#40;78&#44;7&#37;&#41; e hipocr&#243;micas &#40;52&#37;&#41;&#46; Similarmente&#44; las moderadas-graves fueron m&#225;s frecuentes en las mujeres &#40;39&#37; frente a 23&#37;&#41;&#44; aumentaron con la edad &#40;45&#37; en la 9&#170; d&#233;cada frente a 24&#37; en la 5&#170;&#41; y con la progresi&#243;n del da&#241;o renal&#44; medido bien por descenso del filtrado glomerular &#40;G4 49&#37; vs G1 25&#37;&#41; o por albuminuria &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;0&#44;01&#41;&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">No hubo asociaci&#243;n entre el control de la DM&#44; basado en la hemoglobina glicada &#40;HbA1c&#41;&#44; y la anemia en ambos sexos &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;0&#44;887&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusi&#243;n</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Este estudio describe una alta prevalencia de anemia en PDM50&#44; particularmente en las mujeres&#44; en las personas m&#225;s provectas y en presencia de enfermedad renal&#44; incluso en fases tempranas&#44; resaltando la importancia cl&#237;nica de esta coexistencia&#46;</p></span>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A&#41; Etiological classification of the different types of anemia in patients with micro-normocytic anemia with an iron profile performed &#40;N&#8239;&#61;&#8239;1194 PDM50&#41;&#46; B&#41; Prevalences of iron&#44; vitamin B12&#44; and folic acid deficiencies classified by the presence or absence of anemia in PDM50 with an etiological study performed&#46; C&#41; Presence of iron and vitamin B12 deficiencies in PDM50 with anemia classified by different combined red blood cell morphology&#46; IDA &#40;iron-deficiency anemia&#41;&#44; AI &#40;anemia of inflammation&#41;&#44; ARD &#40;anemia of renal disease&#41;&#44; and OC &#40;other causes&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Odds ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37; CI&#58;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;03 to 1&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;63 to 1&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CKD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;83 to 2&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HbA1c&#8239;&#60;&#8239;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;02 to 1&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Use of drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Metformin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;15 to 1&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DPP-4i&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;50 to 1&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>GLP-1ra&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;81 to 1&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>SGLT2i&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;49 to 0&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insulin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;36 to 1&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>RAAS drugs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;36 to 1&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;36 to 1&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anticoagulants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;59 to 2&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Multiple logistic regression analysis of potential factors associated with anemia in 8417 patients with DM&#46; HbA1c &#40;glycated hemoglobin&#41;&#44; CKD &#40;Chronic Kidney Disease&#41;&#44; DPP4i &#40;dipeptidyl peptidase-4 inhibitors&#41;&#44; GLP-1ra &#40;glucagon-like peptide-1 receptor analogs&#41;&#44; RAAS &#40;Renin-Angiotensin-Aldosterone System&#41;&#44; and AP &#40;antiplatelets&#41;&#46;</p>"
        ]
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Global&#44; regional&#44; and national burden of diabetes from 1990 to 2021&#44; with projections of prevalence to 2050&#58; a systematic analysis for the Global Burden of Disease Study 2021"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "GBD 2021 Diabetes Collaborators"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(23)01301-6"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet&#46;"
                        "fecha" => "2023"
                        "volumen" => "402"
                        "paginaInicial" => "203"
                        "paginaFinal" => "234"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/37356446"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of diabetes&#44; use of antidiabetic drugs and degree of glycaemic control in the province of Cadiz &#40;2014-2016&#41;&#58; a population-based study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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