Scientific Letter
Chronic fatigue syndrome in adolescents
Síndrome de fatiga crónica en adolescentes
Ángeles Calle Gómez, Belén Delgado Díez, Ferran Campillo i López, María Angustias Salmerón Ruiz
, José Casas Rivero
Corresponding author
Unidad de Medicina de la Adolescencia, Hospital Universitario La Paz, Madrid, Spain
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"etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 4 => array:2 [ "nombre" => "José" "apellidos" => "Casas Rivero" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Medicina de la Adolescencia, Hospital Universitario La Paz, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de fatiga crónica en adolescentes" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic fatigue syndrome (CFS) or myalgic encephalomyelitis (ME) is a rare disease in adolescents, in whom the incidence is 0.5%. In adults, it has a multifactorial aetiology with no determining factor, primarily affects women (ratio, 2–3:1) aged 20–40 years, and in some cases its onset is associated with an infectious cause (usually viral). In adulthood, CFS is diagnosed based on clinical manifestations and is a diagnosis of exclusion (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>),<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> and while the literature includes descriptions of differences in the paediatric population, few series present data on its particular features in this age group. The management is symptomatic with the goal of improving quality of life. Treatment with selective serotonin reuptake inhibitors (SSRIs), melatonin, methylphenidate, cognitive-behavioural therapy (CBT) and graded exercise has been proven to be effective in these patients.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">We present a series of 12 consecutive cases of CFS diagnosed in patients aged less than 21 years in the adolescent medicine unit of a tertiary care hospital between January 2007 and December 2012. We collected data for demographic variables, symptoms, personal and family history, diagnostic tests performed, treatment given, and response to treatment. We performed the statistical analysis with the Stata<span class="elsevierStyleSup">®</span> v.12.0 software.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We recruited twelve patients, seven male and five female (ratio, 1.4:1). Their median age was 15 years (range, 12–17 years). The median time to diagnosis was 12 months (range, 3–34 months). The duration of school absenteeism ranged between zero and twenty-four months (median, 3 months). <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> presents the frequency of symptoms.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The most salient finding in relation to the personal histories of the patients consisted of viral infections prior to the onset of CFS: four cases of infection by EBV and one by parvovirus. Two patients had psychosomatic disorders that predated the onset of CFS. When it came to a positive history in first-degree relatives, two patients had a family history of psychiatric disorders, three of fibromyalgia and two of poliomyelitis. A complete blood count, electrolyte panel, kidney and liver function panel, thyroid panel, erythrocyte sedimentation rate and serology testing were performed in all patients. Additional tests were required in 71.4% of patients to rule out other diagnoses. All patients were managed with CBT and a graded exercise programme. The prescribed symptomatic treatment consisted of melatonin for sleep-onset insomnia in eight patients, SSRIs for chronic pain in two, and methylphenidate for inattention in five. The median duration of followup was 12 months (range, 2–90 months). When it came to the outcomes, more than half of the patients (58%) experienced a complete resolution, with a median time elapsed to discharge of seven months (range, 2–14 months). The rest experienced partial improvement.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the paediatric age group, CFS is a disease that greatly impacts quality of life, as the onset of symptoms is abrupt and it leads to prolonged absences from school, so it has been proposed that three months of asthenia be considered a diagnostic criterion.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> In adult series there is a predominance of the female sex that is maintained in some paediatric series, and that becomes more pronounced with increasing age.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> However, the ratio described for the paediatric age group approximates one,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> which is consistent with our series. As for the cause, no evidence has been found so far of an infectious aetiology,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> but it seems that a heterogeneous group of pathogens may be capable of triggering the disease, as a history of infection preceding the onset of symptoms has been found in 22–88% of patients.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> In our series, too, 42% of patients had positive serology tests for different viruses. Bould et al. observed that the prevalence of depression was 10 times higher in adolescents with CFS compared to the general population.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> In our series, depression was not diagnosed in any of the patients during the followup. There is evidence that CBT is effective in two thirds of adolescents with CFS.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> The multimodal approach applied in our study included pharmacological treatment, CBT and graded exercise. This achieved complete resolution of the disease in 58% of the patients and considerable improvement in the rest, which is consistent with other series.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our setting, chronic fatigue syndrome is underdiagnosed in children and adolescents; this impacts quality of life, and it is important that it be diagnosed and treated early. The diagnosis is based on clinical manifestations. The approaches used most frequently in its management are graded exercise, CBT and symptomatic treatment.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Calle Gómez Á, Delgado Díez B, Campillo i López F, Salmerón Ruiz MA, Casas Rivero J. Síndrome de fatiga crónica en adolescentes. An Pediatr (Barc). 2016;85:318–320.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">A. Postexertional neuroimmune exhaustion: compulsory:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">1. Marked, rapid physical and/or cognitive fatigability in response to exertion, which may be minimal.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">2. Postexertional symptom exacerbation: e.g. acute flu-like symptoms, pain and worsening of other symptoms.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">3. Postexertional exhaustion may occur immediately after activity or be delayed by hours or days.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">4. Recovery period is prolonged, usually taking 24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h or longer.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">5. Low threshold of physical and mental fatigability (lack of stamina).</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">B. Neurological impairment. At least one symptom from three of the following four symptom categories:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">1. Neurocognitive impairments:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>a. Difficulty processing information \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>b. Short-term memory loss \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">2. Pain:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>a. Headaches \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>b. Myalgia, arthralgia, or generalised hyperalgesia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">3. Sleep disturbance:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>a. Disturbed sleep patterns \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>b. Unrefreshed sleep \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">4. Neurosensory, perceptual and motor disturbances</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">C. Immune, gastrointestinal and genitourinary impairments. At least one symptom from three of the following five symptom categories:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">1. Flu-like symptoms may be recurrent or chronic and typically activate or worsen with exertion</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">2. Susceptibility to viral infections with prolonged recovery periods</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">3. Gastrointestinal tract impairments</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">4. Genitourinary: e.g. urinary urgency or frequency, nocturia</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">5. Sensitivities to food, medications, odours or chemicals</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">D. Energy production/transportation impairments: At least one symptom:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">1. Cardiovascular: orthostatic intolerance, neurally mediated hypotension, postural orthostatic tachycardia syndrome, palpitations with or without cardiac arrhythmias, light-headedness/dizziness.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">2. Respiratory: dyspnoea, fatigue of chest wall muscles</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">3. Loss of thermostatic stability</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">4. Intolerance of extremes of temperature</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Paediatric considerations:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Symptoms may progress more slowly</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">In addition to postexertional neuroimmune exhaustion, the most prominent symptoms tend to be neurological:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1. Headaches: Severe or chronic headaches are often debilitating. Migraine may be accompanied by a rapid drop in temperature, shaking, vomiting, diarrhoea and severe weakness. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2. Neurocognitive impairments: Difficulty focusing eyes and reading are common. Children may become dyslexic, which may only be evident when fatigued. Slow processing of information makes it difficult to follow auditory instructions or take notes. All cognitive impairments worsen with physical or mental exertion. Young people will not be able to maintain a full school programme. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3. Pain may seem erratic and migrate quickly. Joint hypermobility is common. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1261750.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">2011 International Consensus Criteria for myalgic encephalomyelitis in adults, and paediatric considerations.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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">Symptoms \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">Number of patients (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asthenia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sleep disturbances \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (91.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dizzy spells \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (83.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Generalised pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (75) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tonsillitis/cervical lymphadenopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (75) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Flu-like symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (75) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Difficulty concentrating \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (75) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1261749.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Frequency of symptoms.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Myalgic encephalomyelitis: international consensus criteria" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.M. Carruthers" 1 => "M.I. van de Sande" 2 => "K.L. de Meirleir" 3 => "N.G. Klimas" 4 => "G. Broderick" 5 => "T. Mitchell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2796.2011.02428.x" "Revista" => array:6 [ "tituloSerie" => "J Intern Med" "fecha" => "2011" "volumen" => "270" "paginaInicial" => "327" "paginaFinal" => "338" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21777306" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "CFS in children and adolescent: ten years of retrospective clinical evaluation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "I. Elgen" 1 => "O. Hikmat" 2 => "T.N. Aspevik" 3 => "E.M. Hagen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/2013/270373" "Revista" => array:5 [ "tituloSerie" => "Int J Pediatr" "fecha" => "2013" "volumen" => "2013" "paginaInicial" => "270373" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23843800" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The epidemiology of chronic fatigue syndrome/myalgic encephalitis in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. 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Crawley" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/archdischild-2012-303396" "Revista" => array:6 [ "tituloSerie" => "Arch Dis Child" "fecha" => "2013" "volumen" => "98" "paginaInicial" => "425" "paginaFinal" => "428" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23619200" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Internet-based therapy for adolescents with chronic fatigue syndrome: long-term follow-up" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S.L. Nijhof" 1 => "L.P. Priesterbach" 2 => "C.S. Uiterwaal" 3 => "G. Bleijenberg" 4 => "J.L. Kimpen" 5 => "E.M. van de Putte" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1542/peds.2012-2007" "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "2013" "volumen" => "131" "paginaInicial" => "e1788" "paginaFinal" => "e1795" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23669515" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The prognosis of chronic fatigue and chronic fatigue syndrome: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Joyce" 1 => "M. Hotopf" 2 => "S. Wessely" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "QJM" "fecha" => "1997" "volumen" => "90" "paginaInicial" => "223" "paginaFinal" => "233" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9093600" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008500000006/v1_201611291247/S2341287916301168/v1_201611291247/en/main.assets" "Apartado" => array:4 [ "identificador" => "38181" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008500000006/v1_201611291247/S2341287916301168/v1_201611291247/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287916301168?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 9 | 13 |
| 2024 October | 57 | 39 | 96 |
| 2024 September | 74 | 37 | 111 |
| 2024 August | 141 | 67 | 208 |
| 2024 July | 114 | 36 | 150 |
| 2024 June | 103 | 36 | 139 |
| 2024 May | 104 | 37 | 141 |
| 2024 April | 62 | 37 | 99 |
| 2024 March | 86 | 26 | 112 |
| 2024 February | 80 | 29 | 109 |
| 2024 January | 109 | 34 | 143 |
| 2023 December | 135 | 25 | 160 |
| 2023 November | 101 | 28 | 129 |
| 2023 October | 74 | 44 | 118 |
| 2023 September | 57 | 24 | 81 |
| 2023 August | 63 | 20 | 83 |
| 2023 July | 53 | 31 | 84 |
| 2023 June | 69 | 23 | 92 |
| 2023 May | 86 | 33 | 119 |
| 2023 April | 51 | 14 | 65 |
| 2023 March | 78 | 34 | 112 |
| 2023 February | 59 | 20 | 79 |
| 2023 January | 66 | 25 | 91 |
| 2022 December | 60 | 46 | 106 |
| 2022 November | 74 | 37 | 111 |
| 2022 October | 76 | 50 | 126 |
| 2022 September | 48 | 36 | 84 |
| 2022 August | 41 | 53 | 94 |
| 2022 July | 30 | 39 | 69 |
| 2022 June | 44 | 35 | 79 |
| 2022 May | 40 | 30 | 70 |
| 2022 April | 75 | 32 | 107 |
| 2022 March | 76 | 42 | 118 |
| 2022 February | 52 | 28 | 80 |
| 2022 January | 69 | 41 | 110 |
| 2021 December | 62 | 50 | 112 |
| 2021 November | 53 | 48 | 101 |
| 2021 October | 73 | 91 | 164 |
| 2021 September | 32 | 44 | 76 |
| 2021 August | 48 | 49 | 97 |
| 2021 July | 35 | 37 | 72 |
| 2021 June | 52 | 48 | 100 |
| 2021 May | 50 | 59 | 109 |
| 2021 April | 126 | 77 | 203 |
| 2021 March | 100 | 51 | 151 |
| 2021 February | 43 | 29 | 72 |
| 2021 January | 79 | 34 | 113 |
| 2020 December | 64 | 31 | 95 |
| 2020 November | 50 | 26 | 76 |
| 2020 October | 50 | 17 | 67 |
| 2020 September | 89 | 34 | 123 |
| 2020 August | 53 | 36 | 89 |
| 2020 July | 54 | 40 | 94 |
| 2020 June | 59 | 15 | 74 |
| 2020 May | 83 | 30 | 113 |
| 2020 April | 80 | 12 | 92 |
| 2020 March | 61 | 15 | 76 |
| 2020 February | 89 | 6 | 95 |
| 2020 January | 44 | 8 | 52 |
| 2019 December | 68 | 23 | 91 |
| 2019 November | 41 | 13 | 54 |
| 2019 October | 49 | 9 | 58 |
| 2019 September | 30 | 7 | 37 |
| 2019 August | 50 | 18 | 68 |
| 2019 July | 44 | 26 | 70 |
| 2019 June | 45 | 19 | 64 |
| 2019 May | 51 | 41 | 92 |
| 2019 April | 69 | 21 | 90 |
| 2019 March | 41 | 23 | 64 |
| 2019 February | 56 | 12 | 68 |
| 2019 January | 38 | 25 | 63 |
| 2018 December | 40 | 29 | 69 |
| 2018 November | 78 | 31 | 109 |
| 2018 October | 79 | 20 | 99 |
| 2018 September | 44 | 11 | 55 |
| 2018 August | 2 | 0 | 2 |
| 2018 July | 2 | 0 | 2 |
| 2018 June | 2 | 0 | 2 |
| 2018 May | 7 | 0 | 7 |
| 2018 April | 14 | 0 | 14 |
| 2018 March | 21 | 0 | 21 |
| 2018 February | 15 | 0 | 15 |
| 2018 January | 33 | 0 | 33 |
| 2017 December | 24 | 0 | 24 |
| 2017 November | 16 | 0 | 16 |
| 2017 October | 21 | 0 | 21 |
| 2017 September | 26 | 0 | 26 |
| 2017 August | 18 | 0 | 18 |
| 2017 July | 26 | 1 | 27 |
| 2017 June | 23 | 7 | 30 |
| 2017 May | 26 | 11 | 37 |
| 2017 April | 23 | 15 | 38 |
| 2017 March | 15 | 4 | 19 |
| 2017 February | 15 | 9 | 24 |
| 2017 January | 9 | 5 | 14 |
| 2016 December | 31 | 31 | 62 |
| 2016 November | 0 | 14 | 14 |
| 2016 October | 0 | 4 | 4 |
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