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Differences in Clinical Features of Two Immigrant Populations With Tuberculosis
Diferencias en los hallazgos clínicos en dos grupos de población inmigrante afecta de tuberculosis
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In Spain, however, this trend is slowing down, partly due to high numbers of immigrants from countries where this disease is highly prevalent.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The most important factors to consider with regard to immigration are younger age,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> human immunodeficiency virus (HIV) coinfection,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> crowded living conditions, and poor treatment compliance. In 2013 in Barcelona, one of the Spanish cities with the highest flow of immigration, 331 new cases of TB were diagnosed, 126 of which were identified in the districts of Cuitat Vella and Sant Martí. Of these, 56% were from Asian countries, most of whom are registered in Ciutat Vella, where overcrowding is at its worst, and 15% were from Latin American countries. To our knowledge, this is the first study to compare the different characteristics of populations from different origins; differences observed were probably due to their different social conditions. The aim of the study is to determine the differences in the clinical presentation of TB between 2 immigrant populations, and to determine the percentage of resistance in both groups.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Observations</span><p id="par0010" class="elsevierStylePara elsevierViewall">A retrospective descriptive study was conducted of new TB cases (diagnosed during the index visit or subsequent follow-up) in patients from Latin America or Asia, seen in the emergency department between 2006 and 2012. We reviewed the discharge reports from the corresponding medical department (emergency room or hospital ward), with the exception of pediatrics, recording a diagnosis of TB, tuberculosis infection or mycobacterial infection. Diagnosis of TB was considered in cases with microbiological confirmation by culture in Löwenstein-Jensen medium and/or BACTEC<span class="elsevierStyleSup">®</span>. Cases with a clinical picture consistent with TB, pleural effusion and elevated adenosine deaminase (ADA) were also included.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Of the 222 patients with a final diagnosis of TB, 62.6% were immigrants, of whom 49 were from Asia and 45 from Latin America. Countries most represented were Pakistan (37 cases) and Bolivia (11). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the baseline characteristics, most common symptoms and TB site. Radiological findings are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. A chest computed tomography (CT) was performed in 9.1% of the Latin American patients and in 28.3% of the Asian patients (<span class="elsevierStyleItalic">P</span>=0.019). Thus, 2 Latin American patients with a negative chest X-ray could be identified as disease carriers. Latin American patients had a greater percentage of pulmonary TB. Extrapulmonary TB, defined as all TB involvement outside the lung parenchyma, was found in 13 Latin American (29.5%) and 24 (29.9%) Asian patients (<span class="elsevierStyleItalic">P</span>=.044). Ten patients had concomitant pulmonary and extrapulmonary TB (6 from Asia and 4 from Latin America). Sputum bacilloscopy was positive in 83.9% of Latin American patients with pulmonary TB and in 88.5% of those from Asia (<span class="elsevierStyleItalic">P</span>=not significant). Most patients received quadruple therapy (100% of Asians and 93.2% of Latin Americans). Isoniazid resistance was documented in 2 Latin American patients.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">This study highlights differences in 2 groups of immigrants, depending on their place of origin. It is of interest that all HIV-positive patients (11%) were from Latin America, although the rate of coinfection is similar to that described by González-Moreno et al.,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and is slightly higher than the figures reported by the European TB surveillance report.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The proportion of cases of extrapulmonary disease is high in both groups, and almost half the Asian patients had this form (similar to rates in the HIV population<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>). Possible causes for these findings may due to the different social conditions of the patients, both in Spain and in their home countries, and to possible differences in infection dynamics (primary infection or recurrence). Unfortunately, although only 4.2% of the Asian patients had previously documented TB, no reliable data are available in this area. It is interesting to note the high percentage of positive bacilloscopies in both patients compared to Spanish registries,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and the low percentage of resistance (4.5%), similar to that found in other Spanish series.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">To our knowledge, this is the first study performed in our geographical region that evaluates the characteristics of 2 different immigrant populations of patients with TB at the time of receiving care in an emergency department. More studies are needed to detect possible differences in the characteristics of TB in other immigrant populations and in other geographical regions.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres516637" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec537555" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres516636" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec537554" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Observations" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-04-02" "fechaAceptado" => "2014-08-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec537555" "palabras" => array:3 [ 0 => "Tuberculosis" 1 => "Immigrants" 2 => "Clinical features" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec537554" "palabras" => array:3 [ 0 => "Tuberculosis" 1 => "Inmigrantes" 2 => "Hallazgos clínicos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A study was performed to assess differences in the clinical presentation of tuberculosis between two groups of immigrants. Ninety-four patients seen in the emergency room for newly diagnosed tuberculosis between 2006 and 2012 were included. Forty-nine patients were from Asian countries and 45 from Latin America. Mean age [years (SD)] was 35.3 (13) in Asian patients and 33.9 (10) in Latin American patients. Asian subjects were predominantly male (40/49 vs 25/45; <span class="elsevierStyleItalic">P</span>=0.006). Patients from Latin American countries had a higher rate of pulmonary tuberculosis. A higher percentage of Asian patients lived in overcrowded conditions, whereas HIV infection was more frequent among Latin Americans. Most patients were treated with a quadruple regimen. Resistance to isoniazid was documented in two patients from Latin America.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se realizó un estudio descriptivo para identificar posibles diferencias en la presentación clínica de la tuberculosis entre 2 grupos de población inmigrante. Se incluyeron 94 pacientes visitados en urgencias y que fueron diagnosticados de tuberculosis activa en el periodo 2006-12. Cuarenta y nueve pacientes era originarios de Asia Central (A) y 45 de Latinoamérica (LA). La edad media (años [DE]) fue de 35,3 (13) años en los procedentes de A por 33,9 (10) en los de LA. Existía un predominio de varones en asiáticos (40/49 vs. 25/45; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,006). Los pacientes procedentes de LA tenían mayor porcentaje de tuberculosis pulmonar. Los pacientes de A vivían en condiciones de hacinamiento con mayor frecuencia. Los pacientes de LA tenían más antecedentes de seropositividad para el VIH. La mayoría recibió tratamiento cuádruple. Dos pacientes latinoamericanos eran resistentes a isoniazida.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Supervía A, Pallàs O, Piccari L, Herrera Fernández S, Domínguez Álvarez M, Cirera I, et al. Diferencias en los hallazgos clínicos en dos grupos de población inmigrante afecta de tuberculosis. Arch Bronconeumol. 2015;51:e29-e31.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1449 "Ancho" => 1472 "Tamanyo" => 137563 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Radiological findings in study patients.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">HIV: human immunodeficiency virus; SD: standard deviation.</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" 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">Latin America (n=45) \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">Asia (n=49) \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>-value \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">Age (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.9 (10) year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.3 (13) years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Men; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (55.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (81.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.006 \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">Time of stay in Spain (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.4 (5.4) years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.5 (4.3) years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">HIV infection; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.026 \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">Smokers; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (26.78) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (35.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Alcohol; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (8.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (14.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Cannabis users; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Illegal drugs; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Previous tuberculosis; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (13.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Overcrowding<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a>; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (11.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (36.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.06 \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">Fever; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (74.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 (71.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Cough; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (93) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (77.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.03 \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">Dyspnea; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (25.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (12.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Hemoptysis; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (23.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (16.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Pulmonary site; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (81.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (61.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.024 \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">Pleural site; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (27.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (30.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Total extrapulmonary sites; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (29.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (49.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.044 \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">Miliary disease; n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (6.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab833842.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Overcrowded living conditions could only be evaluated in 43 Latin America patients and 47 Asians. Overcrowding was defined as cohabitation with more than 3 people per sleeping quarter.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Baseline Characteristics of the Study Groups, Most Common Symptoms and Tuberculosis Site.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Los cambios en la epidemiología de la tuberculosis: la influencia de los flujos migratorios internacionales" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Fortún" 1 => "P. Martín Dávila" 2 => "E. Navas" 3 => "R. López Vélez" 4 => "V. Pintado" 5 => "J. Cobo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2011.04.002" "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2011" "volumen" => "29" "paginaInicial" => "654" "paginaFinal" => "659" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21723001" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tuberculosis en inmigrantes: diferencias clínico epidemiológicas con la población autóctona (1999-2002)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.M. Ramos" 1 => "M. Masiá" 2 => "J.C. Rodríguez" 3 => "I. Padilla" 4 => "M.J. Soler" 5 => "F. Gutiérrez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2004" "volumen" => "22" "paginaInicial" => "315" "paginaFinal" => "318" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15228896" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Experiencia de una unidad monográfica de tuberculosis: Primeros 500 casos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. González-Moreno" 1 => "M. García Gasalla" 2 => "C. Cifuentes Luna" 3 => "I. Mir Villadrich" 4 => "A. Pareja Bezares" 5 => "V. Navarro Fernández" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arbres.2013.03.010" "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2013" "volumen" => "49" "paginaInicial" => "421" "paginaFinal" => "426" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23791382" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "ECDC surveillance report: Tuberculosis surveillance and monitoring in Europe 2012. Available from: <a href="http://ecdc.europa.eu/en/publications/Publications/1203-Annual-TB-Report.pdf">http://ecdc.europa.eu/en/publications/Publications/1203-Annual-TB-Report.pdf</a> [accessed 11.07.12]." ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Resistencias a fármacos de <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> en la comunidad de Castilla-León (España) 2001-2005: tercer estudio multicéntrico" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Alberte-Castiñeiras" 1 => "A. Campos-Bueno" 2 => "L. López-Urrutia" 3 => "E. Álvarez-Alonso" 4 => "G. Mejías" 5 => "E. Ojeda-Fernández" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2010.02.011" "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2010" "volumen" => "28" "paginaInicial" => "706" "paginaFinal" => "709" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20627375" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005100000006/v1_201505280222/S157921291500097X/v1_201505280222/en/main.assets" "Apartado" => array:4 [ "identificador" => "9347" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Case reports" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005100000006/v1_201505280222/S157921291500097X/v1_201505280222/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157921291500097X?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 1 | 3 |
| 2024 October | 40 | 19 | 59 |
| 2024 September | 42 | 17 | 59 |
| 2024 August | 61 | 40 | 101 |
| 2024 July | 40 | 20 | 60 |
| 2024 June | 59 | 27 | 86 |
| 2024 May | 67 | 44 | 111 |
| 2024 April | 31 | 25 | 56 |
| 2024 March | 36 | 17 | 53 |
| 2024 February | 33 | 20 | 53 |
| 2023 March | 7 | 2 | 9 |
| 2023 February | 27 | 16 | 43 |
| 2023 January | 25 | 33 | 58 |
| 2022 December | 27 | 41 | 68 |
| 2022 November | 39 | 26 | 65 |
| 2022 October | 35 | 30 | 65 |
| 2022 September | 30 | 36 | 66 |
| 2022 August | 31 | 36 | 67 |
| 2022 July | 24 | 37 | 61 |
| 2022 June | 31 | 32 | 63 |
| 2022 May | 30 | 32 | 62 |
| 2022 April | 29 | 34 | 63 |
| 2022 March | 37 | 43 | 80 |
| 2022 February | 25 | 29 | 54 |
| 2022 January | 26 | 40 | 66 |
| 2021 December | 50 | 38 | 88 |
| 2021 November | 50 | 36 | 86 |
| 2021 October | 43 | 36 | 79 |
| 2021 September | 26 | 48 | 74 |
| 2021 August | 23 | 33 | 56 |
| 2021 July | 34 | 33 | 67 |
| 2021 June | 26 | 34 | 60 |
| 2021 May | 34 | 21 | 55 |
| 2021 April | 78 | 100 | 178 |
| 2021 March | 34 | 13 | 47 |
| 2021 February | 31 | 24 | 55 |
| 2021 January | 25 | 16 | 41 |
| 2020 December | 26 | 24 | 50 |
| 2020 November | 26 | 15 | 41 |
| 2020 October | 9 | 14 | 23 |
| 2020 September | 14 | 11 | 25 |
| 2020 August | 22 | 9 | 31 |
| 2020 July | 17 | 20 | 37 |
| 2020 June | 30 | 9 | 39 |
| 2020 May | 25 | 11 | 36 |
| 2020 April | 17 | 14 | 31 |
| 2020 March | 25 | 13 | 38 |
| 2020 February | 29 | 18 | 47 |
| 2020 January | 26 | 15 | 41 |
| 2019 December | 25 | 16 | 41 |
| 2019 November | 29 | 20 | 49 |
| 2019 October | 24 | 14 | 38 |
| 2019 September | 16 | 11 | 27 |
| 2019 August | 23 | 12 | 35 |
| 2019 July | 22 | 16 | 38 |
| 2019 June | 21 | 16 | 37 |
| 2019 May | 22 | 21 | 43 |
| 2019 April | 39 | 24 | 63 |
| 2019 March | 39 | 24 | 63 |
| 2019 February | 32 | 28 | 60 |
| 2019 January | 34 | 17 | 51 |
| 2018 December | 30 | 23 | 53 |
| 2018 November | 67 | 35 | 102 |
| 2018 October | 91 | 26 | 117 |
| 2018 September | 31 | 11 | 42 |
| 2018 May | 14 | 0 | 14 |
| 2018 April | 61 | 9 | 70 |
| 2018 March | 27 | 5 | 32 |
| 2018 February | 48 | 9 | 57 |
| 2018 January | 103 | 7 | 110 |
| 2017 December | 50 | 3 | 53 |
| 2017 November | 12 | 1 | 13 |
| 2017 October | 23 | 23 | 46 |
| 2017 September | 19 | 10 | 29 |
| 2017 August | 26 | 11 | 37 |
| 2017 July | 17 | 8 | 25 |
| 2017 June | 44 | 15 | 59 |
| 2017 May | 33 | 9 | 42 |
| 2017 April | 25 | 33 | 58 |
| 2017 March | 27 | 12 | 39 |
| 2017 February | 15 | 6 | 21 |
| 2017 January | 12 | 7 | 19 |
| 2016 December | 27 | 9 | 36 |
| 2016 November | 32 | 10 | 42 |
| 2016 October | 41 | 11 | 52 |
| 2016 September | 31 | 19 | 50 |
| 2016 August | 30 | 9 | 39 |
| 2016 July | 27 | 12 | 39 |
| 2016 March | 2 | 0 | 2 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 26 | 1 | 27 |
| 2015 September | 10 | 15 | 25 |
| 2015 July | 0 | 1 | 1 |
| 2015 June | 0 | 1 | 1 |
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