Scientific Letter
Should training in paediatric rheumatology be improved? Results of a national survey
¿Debe mejorar la formación en reumatología pediátrica? Resultados de una encuesta nacional
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Resultados de una encuesta nacional" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Paediatric rheumatology has well-defined characteristics, including the diseases included in its scope of practice,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> the training objectives for professionals that practice it<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> and the requirements that must be met by health care units in the field.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> In the United States, this subspecialty has been recognised since 1992 and requires a training programme lasting 3 years. In Europe, a specialist training curriculum of 2 years’ duration has been developed that is endorsed by the Paediatric Rheumatology European Society and the European Board of Rheumatology.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In spite of this, and as is the case of other paediatric subspecialties, specialisation in paediatric rheumatology is still not recognised in Spain.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> In addition, since this field deals with diseases that often have a low prevalence, there are few units with a high level of clinical experience, which results in considerable heterogeneity in management and inadequate specialised training for residents in many hospitals. All of the above can have a negative impact on the care of children with rheumatic disease.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To assess how the care of paediatric patients with rheumatic disease is organised in Spain and the perception of paediatricians and residents in paediatrics of the need for specific training in paediatric rheumatology, we conducted a cross-sectional, multicentre and descriptive nationwide study by means of an anonymous questionnaire (GoogleDocs®). We disseminated the questionnaire among paediatricians and residents of paediatrics in August and September of 2017 through electronic mail and social networks.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We obtained 447 responses (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The sample included 292 physicians specialised in paediatrics (65.1%) and 131 medical residents in paediatrics (29.2%). The remaining 24 respondents (5.3%) were physicians and residents in other specialties (rheumatology, family medicine and immunology). The geographical distribution of responses was: Madrid, 180; Basque Country, 39; Castilla y Leon, 33; Andalusia, 25; Asturias, 23; Catalonia, 22; Balearic Islands, 14; Galicia, 11; Navarre, 8; Castilla-La Mancha, 6; Extremadura, 6; Murcia, 6; and Canary Islands, 3. The distribution by work setting was: primary care (45%), hospital (49%) and private medical practices (6%).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Of all respondents, 56.6% reported that there were no specialists in paediatric rheumatology in their hospitals. A similar percentage (57.2%) believed that the clinician that was mainly responsible for the management of children with rheumatic diseases was a paediatric rheumatologist, with 32.4% reporting that this clinician did not have accredited training in this subspecialty and 24.8% that the clinician did have this training. Another 19.9% reported that the physician usually in charge of these patients was a general paediatrician, while 19.1% reported it was an adult rheumatologist. In addition, 95.3% of respondents advocated for the establishment of accredited training in paediatric rheumatology, and 52.5% considered that this specialised training should last 2 years.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Paediatric rheumatology is one of the most recent paediatrics subspecialties to emerge; at present it is not officially recognised, and there are no established minimum qualifications to practice it or a formal training curriculum on this subspecialty.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Specific education in this field is truly needed,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> as asserted by most respondents (95.3%). In Spain, any professional in the field of paediatrics or of rheumatology can manage children with rheumatic disease. The results of our survey reflect that in 39% of cases, the main professional in charge of the management of children with rheumatoid disease is not a paediatric rheumatologist (general paediatrician in 19.9% and rheumatologist in 19.1%).</p><p id="par0035" class="elsevierStylePara elsevierViewall">We ought to highlight that 24.8% of respondents believed that children with rheumatic disease were managed by paediatric rheumatologists with officially accredited training in the field, even though the subspecialty is not recognised as such in Spain. This discrepancy is due to the confusion of formal “specialization” in a particular field of paediatrics and the completion of a longer rotation, of variable duration, in the last year of the residency programme, the latter being the usual pathway to achieving more specialised knowledge in the absence of a formal accredited curriculum. As an alternative, the establishment of “specific qualification areas” in paediatrics (Royal Decree 639/2014) opened the doors to the regularization of these professional fields, but the decree was repealed on 12/12/2016.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> In the field of paediatric rheumatology, despite the development of a specific training programme by the Education and Training Committee of the Paediatric Rheumatology European Society, there is currently no official consensus or recognition allowing accreditation in this field.</p><p id="par0040" class="elsevierStylePara elsevierViewall">There are some limitations to our survey. To facilitate and simplify participation, we did not ask respondents about their age or sex, so we cannot determine the degree to which the sample was representative of Spanish paediatricians and residents in paediatrics. Furthermore, its dissemination through working groups and social networks and the short period for submitting responses may have been a source of selection bias.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This survey reinforces the perception that training in paediatric rheumatology needs to be improved in Spain. Its findings evince the heterogeneity in the management of paediatric patients with rheumatic disease, while most respondents acknowledge that there was a lack of specific training in this field.</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: Udaondo Gascón C, Murias Loza S, Alcobendas Rueda R, Remesal Camba A, de Inocencio Arocena J. ¿Debe mejorar la formación en reumatología pediátrica? Resultados de una encuesta nacional. An Pediatr (Barc). 2020;92:165–166.</p>" ] ] "multimedia" => array:1 [ 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=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Respondent profile</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Paediatrician \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">292 (65.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Resident in paediatrics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">131 (29.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other (physicians or residents in other medical specialties) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 (5.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Practice setting</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Public university hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">203 (45.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Public hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82 (18.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Private hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (5.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primary care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">138 (30.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Country/city: (open-ended question)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Are there specialists in paediatric rheumatology where you work?</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">189 (42.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">253 (56.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Who is the main person responsible for children with rheumatic disease at your workplace? (if more than one, check the one you think is most involved)</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Paediatric rheumatologist with accredited specialty training \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">111 (24.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Paediatric rheumatologist without accredited specialty training \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">145 (32.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>General paediatrician \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">89 (19.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Adult rheumatologist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86 (19.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Do you think there is a need for specific accredited training in paediatric rheumatology?</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">457 (95.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (3.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2259128.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Answers to the questionnaire on training in paediatric rheumatology.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Libro Blanco de las Especialidades Pediátricas: Reumatología Pediátrica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Asociación Española de Pediatría" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2011" "paginaInicial" => "198" "paginaFinal" => "203" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "European Standards in Medical Training. UEMS 2018.21 – European Training Requirements in Paediatric Rheumatology. PRES Syllabus Committee" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "European Union of Medical Specialists" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "March 2016" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Asociación Española de Pediatría. Libro Blanco de las Especialidades Pediátricas. Minimum Criteria for Paediatric Rheumatology Training Centers. Pediatric Rheumatology European Society. Anexo E14-2. p. 353." ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reumatología pediátrica. Breve historia y situación de la especialidad en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. De Inocencio" 1 => "J. Antón" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3823/1307" "Revista" => array:3 [ "tituloSerie" => "Acta Rheumatol" "fecha" => "2014" "volumen" => "1" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Why should pediatric rheumatology be recognized as a separate subspecialty: an open letter to medical councils and government agencies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.H. Spencer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1546-0096-5-21" "Revista" => array:5 [ "tituloSerie" => "Pediatr Rheumatol Online J" "fecha" => "2007" "volumen" => "5" "paginaInicial" => "21" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18031581" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "España. BOE-A-2017-3480. Sentencia de 12 de diciembre de 2016, de la Sala Tercera del Tribunal Supremo, que anula el Real Decreto 639/2014, de 25 de julio, por el que se regula la troncalidad, la reespecialización troncal y las áreas de capacitación específica, se establecen las normas aplicables a las pruebas anuales de acceso a plazas de formación y otros aspectos del sistema de formación sanitaria especializada en Ciencias de la Salud y se crean y modifican determinados títulos de especialista. «BOE» núm. 77, de 31 de marzo de 2017. p. 24941." ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack454378" "titulo" => "Acknowledgment" "texto" => "<p id="par0050" class="elsevierStylePara elsevierViewall">We thank doctors Lacassagne, Erika Sifuentes and Parichat Khaosut.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000009200000003/v1_202003140714/S2341287919301553/v1_202003140714/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/23412879/0000009200000003/v1_202003140714/S2341287919301553/v1_202003140714/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287919301553?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 9 | 15 |
| 2024 October | 40 | 39 | 79 |
| 2024 September | 37 | 23 | 60 |
| 2024 August | 42 | 47 | 89 |
| 2024 July | 37 | 27 | 64 |
| 2024 June | 34 | 18 | 52 |
| 2024 May | 37 | 27 | 64 |
| 2024 April | 29 | 28 | 57 |
| 2024 March | 27 | 18 | 45 |
| 2024 February | 27 | 33 | 60 |
| 2024 January | 21 | 12 | 33 |
| 2023 December | 19 | 23 | 42 |
| 2023 November | 43 | 27 | 70 |
| 2023 October | 30 | 20 | 50 |
| 2023 September | 18 | 25 | 43 |
| 2023 August | 18 | 11 | 29 |
| 2023 July | 21 | 23 | 44 |
| 2023 June | 16 | 25 | 41 |
| 2023 May | 26 | 23 | 49 |
| 2023 April | 24 | 12 | 36 |
| 2023 March | 31 | 23 | 54 |
| 2023 February | 24 | 9 | 33 |
| 2023 January | 31 | 12 | 43 |
| 2022 December | 51 | 21 | 72 |
| 2022 November | 28 | 22 | 50 |
| 2022 October | 43 | 34 | 77 |
| 2022 September | 23 | 15 | 38 |
| 2022 August | 33 | 44 | 77 |
| 2022 July | 38 | 37 | 75 |
| 2022 June | 29 | 26 | 55 |
| 2022 May | 33 | 42 | 75 |
| 2022 April | 23 | 25 | 48 |
| 2022 March | 50 | 50 | 100 |
| 2022 February | 24 | 31 | 55 |
| 2022 January | 42 | 31 | 73 |
| 2021 December | 27 | 43 | 70 |
| 2021 November | 35 | 31 | 66 |
| 2021 October | 90 | 84 | 174 |
| 2021 September | 53 | 45 | 98 |
| 2021 August | 47 | 46 | 93 |
| 2021 July | 34 | 22 | 56 |
| 2021 June | 28 | 31 | 59 |
| 2021 May | 39 | 42 | 81 |
| 2021 April | 106 | 84 | 190 |
| 2021 March | 47 | 30 | 77 |
| 2021 February | 25 | 14 | 39 |
| 2021 January | 47 | 14 | 61 |
| 2020 December | 35 | 9 | 44 |
| 2020 November | 25 | 18 | 43 |
| 2020 October | 19 | 11 | 30 |
| 2020 September | 38 | 20 | 58 |
| 2020 August | 28 | 17 | 45 |
| 2020 July | 38 | 18 | 56 |
| 2020 June | 13 | 10 | 23 |
| 2020 May | 33 | 18 | 51 |
| 2020 April | 67 | 12 | 79 |
| 2020 March | 66 | 22 | 88 |
| 2020 February | 24 | 7 | 31 |
| 2020 January | 16 | 5 | 21 |
| 2019 December | 18 | 13 | 31 |
| 2019 November | 29 | 5 | 34 |
| 2019 October | 8 | 4 | 12 |
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