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compared to other transmissible infectious diseases&#44; it still is a considerable social&#44; health care and economic burden and remains a top health priority&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Invasive meningococcal disease typically manifests with acute sepsis and&#47;or meningitis that may result in death within a few hours&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> In Spain&#44; despite adequate treatment&#44; its associated mortality is 10&#37;&#44; and 10&#37;&#8211;20&#37; of survivors experience sequelae&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Invasive meningococcal disease poses a challenge to clinicians due to the difficulty of early diagnosis in some patients and to the complexity of the care required by the most severe cases&#46; The initial signs and symptoms are often nonspecific&#44; especially in infants&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> which complicates differential diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;12</span></a> Early administration of antibiotics and initiation of life support are the cornerstones of treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">7&#44;13&#44;14</span></a> In IMD&#44; early identification of patients at risk of having a poor outcome from the first contact with primary care is of vital importance&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a> as early treatment and transfer to intensive care is associated with increased survival and a decreased incidence of sequelae&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a> To this end&#44; several predictors of severity have been proposed&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of our study was to explore the epidemiology and clinical characteristics of IMD in the paediatric population of Navarra in the age of universal vaccination against meningococcus C&#44; and to identify the clinical and laboratory findings at diagnosis that are associated with a poor prognosis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We conducted a retrospective study between 2008 and 2014&#44; a period in which the routine immunisation against meningococcus C was well established that we considered to be long enough to reflect the current situation of IMD&#46; The population under study included every child aged less than 15 years residing in Navarra&#44; which amounted to approximately 95<span class="elsevierStyleHsp" style=""></span>500 inhabitants&#46; We defined a case as any patient aged less than 15 years with clinical manifestations compatible with IMD and with microbiological confirmation of <span class="elsevierStyleItalic">N&#46; meningitidis</span> in blood or cerebrospinal fluid &#40;CSF&#41; samples &#40;isolation in culture&#44; DNA detection by polymerase chain reaction&#44; or antigen detection by immunoassay&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We obtained the epidemiological and microbiological data of all cases from the active IMD surveillance system records included in the Register of Notifiable Diseases of Navarra&#46; We completed this information with data from medical records in 46 cases&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We calculated the incidence of IMD using the population size recorded in the census on January 1 for each age group and year as the denominator&#44; using data from the Instituto Nacional de Estad&#237;stica &#40;National Institute of Statistics&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We defined sepsis&#44; septic shock&#44; severe sepsis and organ dysfunction based on the criteria of the 2005 International Consensus Conference on Pediatric Sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">17</span></a> We classified patients that did not meet the criteria for sepsis but in whom viable bacteria were isolated from blood as cases of bacteraemia&#46; We took into account clinical signs of shock following the Spanish Clinical Practice Guideline on the Management of Invasive Meningococcal Disease<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> &#40;unusual skin colour&#44; peripheral coldness&#44; capillary refill time &#62;2<span class="elsevierStyleHsp" style=""></span>s&#44; mental confusion or decreased level of consciousness&#44; tachycardia or hypotension&#44; respiratory difficulty or pain in the extremities&#41;&#46; We defined disseminated intravascular coagulation &#40;DIC&#41; as the presence of laboratory findings characteristic of this pathology&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">18</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">We defined poor outcome as the presence of permanent sequelae &#40;present 3 months after discharge&#41; or death&#46; The factors analysed for a potential association with poor outcome were&#58; duration of symptoms before arrival to hospital &#40;&#60;12&#59; 12&#8211;23 and &#8805;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; manifestations of sepsis in the absence of meningitis&#44; skin lesions either extensive &#40;generalised or disseminated&#44; found in the trunk and extremities&#41; or advanced &#40;purpura or ecchymosis&#41;&#44; a score of less than 15 in the Glasgow coma scale&#44; one or more episodes of seizures&#44; clinical criteria of severe sepsis&#44; leukopaenia &#40;leucocytes &#60;4500&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; neutropaenia &#40;neutrophils &#60;900&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; thrombocytopaenia &#40;platelets &#60;150<span class="elsevierStyleHsp" style=""></span>000&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; product of platelet and neutrophil counts &#40;PN product&#41; of less than 40&#215;10<span class="elsevierStyleSup">9</span>&#47;L&#44; base excess &#40;BE&#41; of less than &#8722;8&#44; procalcitonin &#40;PCT&#41; greater than 100<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#44; and DIC&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All the cases received inpatient care in the public health care network of Navarra&#44; which consists of one tertiary referral hospital and two regional hospitals&#46; To assess prognostic factors&#44; we analysed the values recorded at the time of admission in any of the hospitals &#40;initial history-taking&#44; physical examination and blood work&#41;&#44; except for DIC&#44; for which we took into account the presence of clinical criteria at any point during the episode of disease&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">To analyse the factors associated with a poor prognosis&#44; we conducted a bivariate analysis comparing each clinical or laboratory finding &#40;independent variable&#41; and poor outcome &#40;dependent variable&#41;&#46; This analysis included the 46 cases for which we had access to medical records&#46; We performed the comparisons with Fisher&#39;s exact test&#46; We defined statistical significance as a <span class="elsevierStyleItalic">p</span>-value of less than &#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Epidemiology</span><p id="par0065" class="elsevierStylePara elsevierViewall">The study included a total of 53 cases of IMD between 2008 and 2014&#46; The incidence of IMD showed a predominantly decreasing trend &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The mean annual incidence was 7&#46;9 cases per 100<span class="elsevierStyleHsp" style=""></span>000 individuals&#46; Cases occurred predominantly in the winter months &#40;weeks 1&#8211;4 and 45&#8211;53&#41;&#46; We found no statistically significant differences between sexes &#40;58&#37; male&#44; 42&#37; female&#41;&#46; The mean age of the patients was 2&#46;7 years &#40;standard deviation &#91;SD&#93;&#44; 4&#46;5 years&#41;&#44; and 83&#37; of the children were aged less than 5 years&#46; The annual incidence was highest in children aged less than one year &#40;40&#46;7 cases per 100<span class="elsevierStyleHsp" style=""></span>000&#41;&#44; followed by children aged 1&#8211;4 years &#40;13&#46;3 cases per 100<span class="elsevierStyleHsp" style=""></span>000&#41; and children aged 5&#8211;14 years &#40;2&#46;1 cases per 100<span class="elsevierStyleHsp" style=""></span>000&#41;&#46; In 87&#37; of patients&#44; the isolate was of the B serogroup&#44; in 4&#37; of the C serogroup and in 2&#37; of the Y serogroup&#46; Eight percent of cases were caused by nontypeable meningococci&#46; Ninety-three percent of patients with IMD had been vaccinated with the MenC vaccine&#46; Of the two cases with group C meningococcus&#44; one was due to vaccination failure &#40;the patient was correctly vaccinated for age&#41; and the other occurred in a child whose parents had refused vaccination&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Clinical and laboratory findings at diagnosis</span><p id="par0070" class="elsevierStylePara elsevierViewall">The most frequent clinical presentation was combined sepsis&#8211;meningitis &#40;36&#37;&#41;&#44; followed by sepsis &#40;34&#37;&#41;&#44; meningitis &#40;17&#37;&#41; and bacteraemia &#40;13&#37;&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The mean time elapsed between the onset of symptoms and seeking care was 23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;3<span class="elsevierStyleHsp" style=""></span>h&#46; Twenty-two percent sought care in the first 12<span class="elsevierStyleHsp" style=""></span>h&#44; forty-eight percent 12&#8211;23<span class="elsevierStyleHsp" style=""></span>h after onset&#44; and thirty percent at 24<span class="elsevierStyleHsp" style=""></span>h or more&#46; Eighty-one percent of patients presenting with sepsis or sepsis&#8211;meningitis sought care in the first 24<span class="elsevierStyleHsp" style=""></span>h compared to forty-three percent of the patients that presented with meningitis or bacteraemia &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;026&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The signs and symptoms present most frequently at diagnosis were fever&#44; exanthem &#40;haemorrhagic in most cases&#41; and signs of shock &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Meningeal signs were negative in 48&#37; of the patients in which meningitis or sepsis&#8211;meningitis was subsequently confirmed&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The complete blood count detected leukocytosis in 82&#37; of patients&#44; neutrophilia in 60&#37; and thrombocytopaenia in 11&#37;&#46; Procalcitonin was elevated in 94&#37; of patients in whom it was measured&#44; and C reactive protein was elevated in 53&#37;&#46; Measurement of pH detected metabolic acidosis in 70&#37; of cases &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Treatment and outcome</span><p id="par0090" class="elsevierStylePara elsevierViewall">All patients with IMD were admitted to the inpatient paediatric ward and 68&#37; were also admitted to the paediatric intensive care unit &#40;PICU&#41; &#40;100&#37; of sepsis&#8211;meningitis&#44; 67&#37; of sepsis and 56&#37; of meningitis cases&#41;&#46; The mean total length of stay was 12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;8 days&#44; while the mean stay in the PICU was 6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;2 days&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The most frequent type of organ dysfunction was cardiovascular &#40;60&#37;&#41;&#44; followed by haematological &#40;58&#37;&#41;&#44; respiratory &#40;42&#37;&#41;&#44; neurologic &#40;36&#37;&#41; and renal &#40;9&#37;&#41;&#46; No patient developed liver dysfunction&#46; Thirteen percent of patients developed DIC and one third had multiple organ dysfunction&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">All the patients received intravenous antibiotherapy &#40;98&#37; cefotaxime and 2&#37; ceftriaxone&#41;&#46; Some patients also required volume expanders &#40;69&#37;&#41;&#44; vasoactive and inotropic agents &#40;67&#37;&#41;&#44; oxygen therapy &#40;65&#37;&#41;&#44; corticosteroids &#40;42&#37;&#41;&#44; intubation &#40;10&#37;&#41; or transfusion of blood products &#40;9&#37;&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Condition at discharge</span><p id="par0105" class="elsevierStylePara elsevierViewall">Two patients aged 10 and 12 months died&#44; resulting in a mortality of 3&#46;8&#37; and a mean annual mortality of 0&#46;3 deaths per 100<span class="elsevierStyleHsp" style=""></span>000 individuals &#40;2&#46;1 deaths per 100<span class="elsevierStyleHsp" style=""></span>000 children &#60;2 years&#41;&#46; The two deaths occurred in patients with multiple organ failure secondary to septic shock that did not respond to treatment&#46; The isolated strain was from serogroup B in one of these patients and nontypeable in the other&#46; In both cases&#44; death occurred within 12<span class="elsevierStyleHsp" style=""></span>h from the onset of symptoms&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Of the 51 patients that survived&#44; 24&#37; experienced some sort of sequela &#40;sepsis group&#44; 39&#37;&#59; sepsis&#8211;meningitis group&#44; 32&#37;&#59; and meningitis group&#44; 11&#37;&#41;&#44; and the sequelae were permanent in 10&#37;&#46; The most frequent temporary sequelae were due to soft tissue necrosis&#46; The permanent sequelae were deafness &#40;40&#37;&#41;&#44; limb amputation &#40;40&#37;&#41; and other neurologic impairment &#40;20&#37;&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Signs associated with poor outcome</span><p id="par0115" class="elsevierStylePara elsevierViewall">A score of less than 15 in the Glasgow Coma Scale &#40;odds ratio &#91;OR&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;2&#41;&#44; having at least one seizure &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#46;3&#41;&#44; clinical manifestations of sepsis in the absence of meningitis &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;1&#41;&#44; thrombocytopaenia &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#46;5&#41; and DIC &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#46;9&#41; were significantly associated with poor outcome &#40;<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>&#41;&#46; The association for extensive or advanced skin lesions did not reach statistical significance&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">We found a decreasing incidence of IMD in Navarra between 2008 and 2014&#44; as has been documented for the rest of Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a> The increased incidence in winter<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a> and the greater burden of disease in young children are consistent with the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;2</span></a> As is the case in other Western countries&#44; we found a significant predominance of serogroup B&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">19</span></a> The low incidence of cases caused by serogroup B is associated with the high vaccination coverage with the MenC vaccine in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The most frequent clinical presentation was sepsis&#44; but in the literature there is variation in the most predominant form&#8212;sepsis or meningitis&#8212;from study to study&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;21</span></a> Patients presenting with sepsis and sepsis&#8211;meningitis sought care before patients with other forms of disease&#44; probably on account of the rapid progression and severity of these cases&#46; Fever and exanthem&#44; which are symptoms frequently described in cases of IMD&#44;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">15&#44;21&#44;22</span></a> were the manifestations found most frequently at the time of diagnosis&#46; The exanthem was not haemorrhagic in two out of ten patients&#44; which is a relevant finding&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> as less serious infections in children often present with non-haemorrhagic exanthem&#46; Consistent with other studies&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> a considerable proportion of patients presented with some sign of shock on arrival to the hospital&#46; This fact is worth noting&#44; as some of these signs manifest in the early stages<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> and knowing how to recognise them is important for the purpose of early diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;12</span></a> Meningeal signs were negative in almost one out of every two patients presenting with sepsis&#8211;meningitis or meningitis&#44; possibly because they manifest at a later time or because they often do not develop in infants&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">7&#44;11</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The abnormal laboratory findings were consistent with the previous literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">15&#44;23</span></a> The proportion of patients with elevated PCT was higher than the proportion with elevated C-reactive protein&#46; This may be related to the rapid progression of most cases and supports the hypothesis that due to its earlier elevation&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">24</span></a> PCT is more useful in the diagnosis of meningococcal disease&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">25</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In IMD&#44; there is a massive activation of the inflammatory cascade and the coagulation pathway&#44; which causes damage to the internal organs of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> The severity of this disease is evinced by the percentage of patients admitted to the PICU and the need for life support measures&#46; Our findings are consistent with those of other authors as to lethality&#44; mortality and mean length of stay&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> with most deaths occurring in the first 24<span class="elsevierStyleHsp" style=""></span>h&#44;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;21</span></a> and the frequency and type of sequelae&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Many studies have analysed clinical and laboratory markers&#44; alone or in the form of scales&#44; as potential prognostic factors in IMD&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">16&#44;26&#8211;32</span></a> In our study&#44; sepsis without meningitis&#44; seizure&#44; and a score of less than 15 in the Glasgow Coma Scale were the clinical factors with the highest predictive value for a poor outcome&#46; We did not find an association between the duration of symptoms and poor outcome&#44; probably because the most severe cases tend to seek care earlier and counteract a worse initial prognosis with earlier initiation of care&#46; The association with the presence of extensive or advanced exanthem was not statistically significant&#44; but is nevertheless considered relevant in prognostication&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">7&#44;30&#44;33</span></a> Thrombocytopaenia and DIC were the laboratory parameters that best predicted a poor outcome&#46; This is a relevant finding&#44; as the platelet count is an accessible and economic test with a demonstrated predictive value<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a> that is used in various composite scales&#44; such as the PN product&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Protocols for the management of paediatric patients with IMD can incorporate thrombocytopaenia as a marker for poor prognosis&#44; one that could be particularly useful in facilities in which more sophisticated tests for other markers are not available&#46; Children with thrombocytopaenia or other abnormal laboratory findings compatible with DIC&#44; as well as children presenting with sepsis but not meningitis&#44; a score of less than 15 in the Glasgow Coma Scale or that experience seizures should be considered at high risk&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The findings of this study must be interpreted taking its limitations into account&#46; Although our study included all cases of IMD in Navarra&#44; the sample size was small and restricted to a specific geographical area&#46; The retrospective design may have led to biases&#46; We did not consider whether patients with IMD had previously visited their primary care clinic or collect data for other symptoms such as headache&#44; vomiting or photophobia&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">15&#44;21</span></a> We were unable to obtain the laboratory values for all the patients&#46; In some cases that resulted in permanent sequelae or death&#44; the PCT&#44; BE and leukocytecountin CSF were not available&#44; so the association of these parameters with a poor outcome may be stronger than found in our analysis&#46; Furthermore&#44; in most cases&#44; BE was measured in samples of venous blood&#44; and the presence of DIC&#44; which was documented at more advanced stages&#44; may have been given more weight than other factors&#46; We did not analyse psychological sequelae&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The recent introduction in the market of the meningococcal B vaccine in Spain marks the dawn of a new era in the prevention of IMD&#46; This new development will probably lead to changes in this disease in the near future&#44; so the situation that we have described may serve as the starting point for new studies evaluating the impact of the new vaccine in coming years&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">To conclude&#44; despite the significant advances made in the prevention of IMD with the routine immunisation of children against serogroup C meningococcus&#44; the disease continues to be a significant health problem in the paediatric age group&#46; The early recognition of symptoms&#44; the optimisation of initial treatment in emergency care settings and the urgent transfer of patients to facilities with a PICU are key strategies to reducing mortality and the incidence of sequelae in children with IMD&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec817002"
          "palabras" => array:5 [
            0 => "Enfermedad meningoc&#243;cica"
            1 => "Epidemiolog&#237;a"
            2 => "Caracter&#237;sticas cl&#237;nicas"
            3 => "Factores pron&#243;sticos"
            4 => "Vacuna conjugada"
          ]
        ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Systematic childhood vaccination against meningococcus C has had a considerable impact on meningococcal invasive disease &#40;MID&#41;&#46; The aim of this study is to perform an analysis on the epidemiology&#44; the clinical features&#44; and the factors associated with a worse prognosis of MID&#44; in the era of a meningococcal C vaccine&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The study included confirmed cases of MID in children less than 15 years of age in Navarra&#44; Spain&#44; between 2008 and 2014&#46; The risk of death or permanent sequelae was evaluated according to the presence of clinical features and analytical parameters at diagnosis&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The average annual incidence was 7&#46;9 cases per 100<span class="elsevierStyleHsp" style=""></span>000 children&#44; with the highest attack rate in children &#60;1 year&#46; Of 53 cases analysed&#44; 87&#37; were due to meningococcus B&#46; Fever &#40;100&#37;&#41;&#44; rash &#40;91&#37;&#41;&#44; and elevation of procalcitonin &#40;94&#37;&#41; were the most frequent findings at diagnosis&#46; Some sign of shock was observed in 70&#37; upon arrival at the hospital&#46; The case-fatality rate was 3&#46;8&#37; and 10&#37; survived with permanent sequelae&#46; Glasgow coma scale &#60;15 &#40;odds ratio &#91;OR&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;2&#41;&#44; seizure &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#46;3&#41;&#44; sepsis without meningitis &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;1&#41;&#44; thrombocytopenia &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#46;5&#41;&#44; and disseminated intravascular coagulation &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#46;9&#41; showed a greater association with a worse prognosis&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The MID continues to be a significant cause of morbidity and mortality in children&#46; Therefore&#44; new advances are needed in the prevention&#44; early diagnosis&#44; and detection of the factors associated with poor prognosis&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La vacunaci&#243;n sistem&#225;tica infantil frente al meningococo C ha tenido un impacto considerable en la enfermedad meningoc&#243;cica invasiva &#40;EMI&#41;&#46; El objetivo de este estudio es analizar la epidemiolog&#237;a&#44; las manifestaciones cl&#237;nicas y los factores asociados a un peor pron&#243;stico de la EMI en la era de la vacuna antimeningoc&#243;cica C&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se analizaron los casos de EMI confirmados en menores de 15 a&#241;os diagnosticados en Navarra entre 2008 y 2014&#44; y se evalu&#243; el riesgo de muerte o secuelas permanentes&#44; seg&#250;n la presencia de determinados hallazgos cl&#237;nicos o anal&#237;ticos al diagn&#243;stico&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La incidencia media anual fue 7&#44;9 casos por 100&#46;000 ni&#241;os&#44; con mayor tasa de ataque en ni&#241;os &#60; 1 a&#241;o&#46; De 53 casos analizados&#44; el 87&#37; fueron por meningococo B&#46; Fiebre &#40;100&#37;&#41;&#44; exantema &#40;91&#37;&#41; y elevaci&#243;n de la procalcitonina &#40;94&#37;&#41; fueron los hallazgos m&#225;s frecuentes al diagn&#243;stico&#46; El 70&#37; de los casos presentaba alg&#250;n signo de shock a su llegada al hospital&#46; La letalidad fue del 3&#44;8&#37; y un 10&#37; sobrevivi&#243; con secuelas permanentes&#46; Una puntuaci&#243;n en la escala de coma de Glasgow &#60; 15 &#40;odds ratio &#91;OR&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#44;2&#41;&#44; convulsi&#243;n &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#44;3&#41;&#44; sepsis sin meningitis &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#44;1&#41;&#44; trombocitopenia &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#44;5&#41; y coagulaci&#243;n intravascular diseminada &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#44;9&#41; se asociaron con un peor pron&#243;stico&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La EMI contin&#250;a causando una morbimortalidad importante en la poblaci&#243;n infantil&#44; por lo que sigue siendo necesario avanzar en su prevenci&#243;n&#44; en su diagn&#243;stico temprano y en reconocer los factores asociados a mal pron&#243;stico&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Introducci&#243;n"
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            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Morales D&#44; Moreno L&#44; Herranz M&#44; Bernaola E&#44; Mart&#237;nez-Baz I&#44; Castilla J&#46; Enfermedad meningoc&#243;cica invasiva en Navarra en la era de la vacuna conjugada antimeningoc&#243;cica C&#46; An Pediatr &#40;Barc&#41;&#46; 2017&#59;86&#58;213&#8211;219&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Incidence of invasive meningococcal disease in children aged less than 15 years in Navarra&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">One patient died on admission to hospital&#44; so no laboratory data were available&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Procalcitonin level measurement started in year 2009&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total <span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Frequency<br><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Axillary temperature &#8805;38</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#176;C</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46 &#40;100&#41;&nbsp;\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>Axillary temperature &#8805;39<span class="elsevierStyleHsp" style=""></span>&#176;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35 &#40;76&#41;&nbsp;\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">Exanthem</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;91&#41;&nbsp;\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>Haemorrhagic exanthem&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;72&#41;&nbsp;\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">Signs of shock</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;70&#41;&nbsp;\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">Glasgow Coma Scale score &#60;15</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;46&#41;&nbsp;\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">Seizure</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Blood test values</span></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>Procalcitonin &#62;0&#46;5<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;94&#41;&nbsp;\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>Leucocytes &#62;10<span class="elsevierStyleHsp" style=""></span>000&#47;mm<span class="elsevierStyleSup">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;82&#41;&nbsp;\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>Base excess &#60;&#8722;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;70&#41;&nbsp;\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>Polymorphonuclear leukocytes &#62;70&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;60&#41;&nbsp;\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>C-reactive protein &#62;10<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;53&#41;&nbsp;\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>Platelets &#60;150<span class="elsevierStyleHsp" style=""></span>000&#47;mm<span class="elsevierStyleSup">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;11&#41;&nbsp;\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>Leucocytes &#60;4500&#47;mm<span class="elsevierStyleSup">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;9&#41;&nbsp;\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>Neutrophils &#60;900&#47;mm<span class="elsevierStyleSup">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Clinical and laboratory findings at diagnosis in patients with invasive meningococcal disease aged less than 15 years in Navarra&#44; 2008&#8211;2014&#46;</p>"
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                  <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">Clinical factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total <span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Poor outcome<br><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Crude odds ratio &#40;95&#37; confidence interval&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Sepsis without meningitis</span></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>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;6&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;38&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;1 &#40;1&#46;5&#8211;78&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Severe sepsis</span></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>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;20&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;1 &#40;0&#46;5&#8211;102&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;209&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Extensive&#47;advanced skin lesions</span></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>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;4&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;26&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;5 &#40;1&#46;0&#8211;187&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;053&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Glasgow Coma Scale score &#60;15</span></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>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;2 &#40;1&#46;2&#8211;230&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;030&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Time elapsed between onset of symptoms to seeking care</span></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>&#60;12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;10&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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>12&#8211;23<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;18&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;0 &#40;0&#46;2&#8211;4&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;000&nbsp;\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>&#8805;24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;14&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;5 &#40;0&#46;1&#8211;19&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Seizures</span></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>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;10&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;50&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;3 &#40;1&#46;1&#8211;65&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;040&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <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">Laboratory parameters &#40;tested in blood&#44; except the last&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total <span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Poor outcome<br><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Crude odds ratio &#40;95&#37; confidence interval&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Leucocytes &#60;4500&#47;mm</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">3</span></span></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>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;12&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;25&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;3 &#40;0&#46;1&#8211;27&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;528&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Neutrophils &#60;900&#47;mm</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">3</span></span></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>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;11&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;6 &#40;0&#46;1&#8211;54&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;399&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Platelets &#60;150</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">000&#47;mm</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">3</span></span></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>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;5&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;66&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#46;5 &#40;3&#46;6&#8211;377&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Procalcitonin &#62;100</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ng&#47;mL</span></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>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;3&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;7 &#40;0&#46;9&#8211;526&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;068&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Disseminated intravascular coagulation</span></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>No&nbsp;\t\t\t\t\t\t\n
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                  \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>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;50&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \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>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;5 &#40;0&#46;1&#8211;206&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;400&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;11&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not available&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;133&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Leucocytesin cerebrospinal fluid &#60;10&#47;mm</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">3</span></span></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>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;10&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#46;0&#8211;34&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;808&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Laboratory findings associated with poor outcome in patients with invasive meningococcal disease aged less than 15 years in Navarra&#44; 2008&#8211;2014&#46;</p>"
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                    0 => array:2 [
                      "titulo" => "Which early &#8220;red flag&#8221; symptoms identify children with meningococcal disease in primary care"
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                        0 => array:2 [
                          "etal" => true
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                            0 => "T&#46;A&#46; Haj-Hassan"
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        "texto" => "<p id="par0170" class="elsevierStylePara elsevierViewall">We thank Dr Federico Martin&#243;n-Torres &#40;and his colleagues&#41;&#44; co-coordinator of the ESIGEM study&#44; for his willingness to collaborate with us on this study&#46;</p>"
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