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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La enfermedad meningoc&#243;cica invasiva &#40;EMI&#41;&#44; producida por la bacteria <span class="elsevierStyleItalic">Neisseria meningitidis &#40;N&#46; meningitidis&#41;</span> &#40;meningococo&#41;&#44; es una infecci&#243;n grave que afecta principalmente a ni&#241;os peque&#241;os<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1-4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En Espa&#241;a&#44; tras la introducci&#243;n de la vacuna conjugada frente al serogrupo C &#40;MenCC&#41; en el calendario de vacunaci&#243;n infantil en 2001&#44; la incidencia de EMI descendi&#243;&#44; hasta situarse en torno a 0&#44;8 casos anuales por 100&#46;000 habitantes en 2012-2013<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a>&#46; Sin embargo&#44; respecto a otras enfermedades infecto-contagiosas&#44; causa un importante impacto social&#44; m&#233;dico y econ&#243;mico&#44; siendo considerada una prioridad sanitaria de primer orden<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">6&#44;7</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La EMI suele manifestarse como un cuadro agudo de sepsis y&#47;o meningitis que puede desencadenar la muerte del enfermo en pocas horas<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a>&#46; En nuestro medio&#44; a&#250;n con el tratamiento adecuado&#44; la letalidad ronda el 10&#37;&#44; y el 10-20&#37; de los casos que sobreviven presentan secuelas<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">8&#44;9</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La EMI supone un reto para los cl&#237;nicos&#44; por un lado&#44; porque el diagn&#243;stico temprano en ocasiones es complicado&#44; y por otro lado&#44; por la complejidad terap&#233;utica de los casos m&#225;s graves&#46; Las manifestaciones cl&#237;nicas iniciales a menudo son inespec&#237;ficas&#44; sobre todo en los lactantes<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a>&#44; dificultando el diagn&#243;stico diferencial<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;12</span></a>&#46; La administraci&#243;n temprana de antibi&#243;ticos y la instauraci&#243;n de medidas de soporte son los pilares terap&#233;uticos<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">7&#44;13&#44;14</span></a>&#46; En esta enfermedad&#44; resulta de vital importancia el reconocimiento temprano de los pacientes con peor pron&#243;stico desde la primera atenci&#243;n sanitaria<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a>&#44; ya que el tratamiento precoz y el traslado a unidades de cuidados intensivos&#44; aumentan las probabilidades de supervivencia y reducen las secuelas<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a>&#46; Con este prop&#243;sito&#44; se han propuesto diversos factores predictores de gravedad<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El objetivo de este estudio es conocer la epidemiolog&#237;a y la cl&#237;nica de la EMI en la poblaci&#243;n infantil de Navarra en la era de vacunaci&#243;n universal frente al meningococo C e identificar los hallazgos cl&#237;nicos y anal&#237;ticos al diagn&#243;stico que predicen a una peor evoluci&#243;n&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall">Estudio retrospectivo desde 2008 hasta 2014&#44; a&#241;os en los que el programa de vacunaci&#243;n infantil frente al meningococo C estaba completamente asentado&#44; considerando que el periodo pudiera resultar suficiente para reflejar la situaci&#243;n de la EMI&#46; La poblaci&#243;n de estudio fueron todos los menores de 15 a&#241;os residentes en Navarra&#44; unos 95&#46;500 habitantes&#46; Se consider&#243; caso a todo paciente menor de 15 a&#241;os con cl&#237;nica compatible con EMI y confirmaci&#243;n microbiol&#243;gica de identificaci&#243;n de <span class="elsevierStyleItalic">N&#46; meningitidis</span> &#40;aislamiento en cultivo&#44; detecci&#243;n de ADN por reacci&#243;n en cadena de la polimerasa o del ant&#237;geno por t&#233;cnicas inmunol&#243;gicas&#41; en sangre o l&#237;quido cefalorraqu&#237;deo&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Los datos epidemiol&#243;gicos y microbiol&#243;gicos de todos los casos se obtuvieron del sistema de vigilancia activa de la EMI a trav&#233;s del Registro de Enfermedades de Declaraci&#243;n Obligatoria de Navarra&#46; Esta informaci&#243;n se complet&#243; con los datos de la historia cl&#237;nica en 46 de los casos&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Las tasas de incidencia se calcularon tomando como denominador la poblaci&#243;n del padr&#243;n a 1 de enero para cada grupo de edad y a&#241;o&#44; seg&#250;n el Instituto Nacional de Estad&#237;stica&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se defini&#243; sepsis&#44; shock s&#233;ptico&#44; sepsis grave y disfunci&#243;n org&#225;nica seg&#250;n los criterios publicados en el consenso de la Conferencia Internacional de Sepsis Pedi&#225;trica de 2005<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">17</span></a>&#46; Los pacientes en los que&#44; sin cumplir criterios de sepsis&#44; se aislaron bacterias viables en sangre se clasificaron como bacteriemias&#46; Se tuvieron en cuenta los signos cl&#237;nicos de shock seg&#250;n la Gu&#237;a espa&#241;ola de Pr&#225;ctica Cl&#237;nica sobre el Manejo de la Enfermedad Meningoc&#243;cica Invasiva<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> &#40;color an&#243;malo de la piel&#44; frialdad acra&#44; relleno capilar &#62;<span class="elsevierStyleHsp" style=""></span>2&#8221;&#44; confusi&#243;n mental o disminuci&#243;n del nivel de consciencia&#44; taquicardia o hipotensi&#243;n&#44; dificultad respiratoria o dolor de extremidades&#41;&#46; Se defini&#243; el estado de coagulaci&#243;n intravascular diseminada &#40;CID&#41; por la presencia de hallazgos de laboratorio propios de esta entidad<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Se consider&#243; mala evoluci&#243;n la presencia de secuelas permanentes &#40;presentes 3 meses despu&#233;s del alta&#41; o la muerte&#46; Los factores analizados por su posible asociaci&#243;n con una mala evoluci&#243;n fueron&#58; el tiempo de evoluci&#243;n de los s&#237;ntomas hasta la llegada al hospital &#40;&#60;<span class="elsevierStyleHsp" style=""></span>12&#59; 12-23 y &#8805; 24 h&#41;&#44; la cl&#237;nica de sepsis sin meningitis&#44; las lesiones cut&#225;neas extensas &#40;generalizadas o diseminadas incluyendo el tronco y las extremidades&#41; o evolucionadas &#40;p&#250;rpura o equimosis&#41;&#44; la puntuaci&#243;n &#60; 15 en la escala de coma de Glasgow&#44; uno o m&#225;s episodios convulsivos&#44; criterios cl&#237;nicos de sepsis grave&#44; leucopenia &#40;leucocitos &#60; 4&#46;500&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; neutropenia &#40;neutr&#243;filos &#60; 900&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; trombocitopenia &#40;plaquetas &#60; 150&#46;000&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; producto de plaquetas<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>neutr&#243;filos &#40;PN&#41; &#60;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>&#215;10<span class="elsevierStyleSup">9</span>&#47;L&#44; exceso de bases &#40;EB&#41; &#60; &#8211;8&#44; procalcitonina &#40;PCT&#41; &#62; 100<span class="elsevierStyleHsp" style=""></span>ng&#47;mL y CID&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Todos los casos recibieron asistencia hospitalaria en la red sanitaria p&#250;blica de Navarra&#44; compuesta por un hospital de referencia y 2 hospitales comarcales&#46; Para evaluar los factores pron&#243;sticos&#44; se analizaron los valores registrados en el momento del ingreso en cualquiera de los centros hospitalarios &#40;primera anamnesis&#44; exploraci&#243;n f&#237;sica y anal&#237;tica de sangre&#41;&#44; excepto para la CID&#44; en la que se tuvo en cuenta la presencia de los criterios diagn&#243;sticos en cualquier momento del episodio cl&#237;nico&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Para estudiar los factores asociados a mala evoluci&#243;n&#44; se realiz&#243; un an&#225;lisis bivariante entre cada hallazgo cl&#237;nico o anal&#237;tico &#40;variable independiente&#41; y el desenlace de mala evoluci&#243;n &#40;variable dependiente&#41;&#46; En este an&#225;lisis&#44; se incluyeron los 46 casos de los cuales se dispuso de la informaci&#243;n cl&#237;nica&#46; La comparaci&#243;n se realiz&#243; empleando el test exacto de Fisher&#46; La significaci&#243;n estad&#237;stica se consider&#243; a partir del valor de p &#60; 0&#44;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Epidemiolog&#237;a</span><p id="par0065" class="elsevierStylePara elsevierViewall">Entre 2008 y 2014 se incluyeron un total de 53 casos de EMI&#46; La incidencia sigui&#243; una tendencia predominantemente decreciente &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; La incidencia media anual fue de 7&#44;9 casos por 100&#46;000 habitantes&#46; Los casos se presentaron predominantemente durante los meses de invierno &#40;semanas 1 a 4&#44; y 45 a 53&#41;&#46; No hubo diferencias significativas en la distribuci&#243;n por sexo &#40;58&#37; varones y 42&#37; mujeres&#41;&#46; La media de edad de los casos fue de 2&#44;7 a&#241;os &#40;desviaci&#243;n est&#225;ndar &#91;DE&#93; 4&#44;5 a&#241;os&#41;&#44; siendo el 83&#160;&#37; de los ni&#241;os menores de 5 a&#241;os&#46; La incidencia media anual m&#225;s alta se registr&#243; en los menores de un a&#241;o con 40&#44;7 casos por 100&#46;000&#44; seguidos de los de 1 a 4 a&#241;os con 13&#44;3 por 100&#46;000 y los de 5 a 14 a&#241;os con 2&#44;1 casos por 100&#46;000&#46; En el 87&#37; de los pacientes se aisl&#243; el meningococo serogrupo B&#44; en el 4&#37; el serogrupo C y en el 2&#37; el serogrupo Y&#46; El 8&#37; de ellos fueron debidos a meningococos no grupados&#46; El 93&#37; de los casos hab&#237;an recibido la vacuna MenCC&#46; De los 2 casos por serogrupo C&#44; uno fue un fallo vacunal &#40;paciente correctamente vacunado para su edad&#41; y el otro fue un ni&#241;o no vacunado por decisi&#243;n paterna&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Hallazgos cl&#237;nicos y anal&#237;ticos al diagn&#243;stico</span><p id="par0070" class="elsevierStylePara elsevierViewall">La forma cl&#237;nica m&#225;s frecuente fue la mixta de sepsis-meningitis &#40;36&#37;&#41;&#44; seguida de la sepsis &#40;34&#37;&#41;&#44; la meningitis &#40;17&#37;&#41; y la bacteriemia &#40;13&#37;&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">El tiempo medio &#177; DE transcurrido desde el inicio de los s&#237;ntomas hasta la consulta fue de 23 &#177; 6&#44;3 h&#46; Consultaron en &#60; 12 h un 22&#37;&#44; en 12-23 h un 48&#37; y en &#8805; 24 h un 30&#37; de los casos&#46; El 81&#37; de los casos de sepsis y sepsis-meningitis consultaron en las primeras 24 h frente al 43&#160;&#37; de las meningitis y bacteriemias &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;026&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">De los s&#237;ntomas y signos al diagn&#243;stico&#44; los m&#225;s frecuentes fueron la fiebre&#44; el exantema &#40;en su mayor&#237;a hemorr&#225;gico&#41; y los signos de shock &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; En el 48&#37; de los casos en los que posteriormente se confirm&#243; meningitis o sepsis-meningitis&#44; los signos men&#237;ngeos fueron negativos&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">En el hemograma&#44; el 82&#37; de los pacientes presentaron leucocitosis&#44; el 60&#37; neutrofilia y el 11&#37; trombocitopenia&#46; Se encontr&#243; elevaci&#243;n de la PCT en el 94&#37; de los casos en los que se determin&#243; y de la prote&#237;na C reactiva en el 53&#37;&#46; La pH-metr&#237;a mostr&#243; acidosis metab&#243;lica en el 70&#37; de los casos &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Evoluci&#243;n y tratamiento</span><p id="par0090" class="elsevierStylePara elsevierViewall">Todos los casos ingresaron en la planta de hospitalizaci&#243;n pedi&#225;trica y el 68&#37; tambi&#233;n en la Unidad de Cuidados Intensivos Pedi&#225;trica &#40;UCIP&#41; &#40;100&#37; de las sepsis-meningitis&#44; 67&#37; de las sepsis y 56&#37; de las meningitis&#41;&#46; La media &#177; DE de estancia hospitalaria total fue de 12 &#177; 9&#44;8 d&#237;as y de 6 &#177; 7&#44;2 d&#237;as en la UCIP&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La disfunci&#243;n org&#225;nica m&#225;s frecuente fue la cardiovascular &#40;60&#37;&#41;&#44; seguida de la hematol&#243;gica &#40;58&#37;&#41;&#44; la respiratoria &#40;42&#37;&#41;&#44; la neurol&#243;gica &#40;36&#37;&#41; y la renal &#40;9&#37;&#41;&#46; Ning&#250;n paciente desarroll&#243; disfunci&#243;n hep&#225;tica&#46; Un 13&#37; de los casos presentaron CID y un tercio de los pacientes tuvo afectaci&#243;n multiorg&#225;nica&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Todos los enfermos recibieron tratamiento antibi&#243;tico por v&#237;a intravenosa &#40;98&#37; cefotaxima y 2&#37; ceftriaxona&#41;&#46; Algunos casos tambi&#233;n precisaron tratamiento con expansores del plasma &#40;69&#37;&#41;&#44; f&#225;rmacos vasoactivos e inotr&#243;picos &#40;67&#37;&#41;&#44; oxigenoterapia &#40;65&#37;&#41;&#44; corticoterapia &#40;42&#37;&#41;&#44; intubaci&#243;n &#40;10&#37;&#41; y transfusiones de hemoderivados &#40;9&#37;&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Estado al alta</span><p id="par0105" class="elsevierStylePara elsevierViewall">Fallecieron 2 pacientes de 10 y 12 meses de edad&#44; siendo la letalidad del 3&#44;8&#37; y la tasa de mortalidad media anual de 0&#44;3 muertes por cada 100&#46;000 habitantes &#40;2&#44;1 muertes por cada 100&#46;000 ni&#241;os &#60; 2 a&#241;os&#41;&#46; Los dos fallecimientos presentaron un fallo multiorg&#225;nico secundario a un shock s&#233;ptico refractario al tratamiento&#46; En uno se aisl&#243; un meningococo serogrupo B y en otro un meningococo no grupado&#46; En ambos casos la muerte se produjo en las primeras 12 h desde el inicio de los s&#237;ntomas&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">De los 51 pacientes que sobrevivieron&#44; present&#243; alg&#250;n tipo de secuela el 24&#37; &#40;39&#37; de las sepsis&#44; 32&#37; de las sepsis-meningitis y 11&#37; de las meningitis&#41;&#44; que fueron permanentes en el 10&#37;&#46; Las secuelas temporales m&#225;s frecuentes fueron las debidas a necrosis de tejidos blandos&#46; Las secuelas permanentes fueron sordera &#40;40&#37;&#41;&#44; amputaciones en miembros &#40;40&#37;&#41; y otros d&#233;ficits neurol&#243;gicos &#40;20&#37;&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Signos asociados a mala evoluci&#243;n</span><p id="par0115" class="elsevierStylePara elsevierViewall">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; haber presentado al menos una convulsi&#243;n &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#44;3&#41;&#44; la cl&#237;nica de sepsis sin meningitis &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#44;1&#41;&#44; la trombocitopenia &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#44;5&#41; y la CID &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#44;9&#41; se asociaron significativamente a una peor evoluci&#243;n &#40;<a class="elsevierStyleCrossRefs" href="#tbl0010">tablas 2 y 3</a>&#41;&#46; Las lesiones cut&#225;neas extensas o evolucionadas no alcanzaron la significaci&#243;n estad&#237;stica&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0120" class="elsevierStylePara elsevierViewall">Entre 2008 y 2014 en Navarra se registr&#243; una incidencia decreciente de EMI en ni&#241;os&#44; de la misma forma que en el resto de Espa&#241;a<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a>&#46; El aumento de los casos en invierno<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a> y la mayor carga de enfermedad en ni&#241;os peque&#241;os&#44; concuerdan con lo descrito<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Como en otros pa&#237;ses occidentales&#44; existe un predominio importante del serogrupo B<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">19</span></a>&#46; La baja incidencia de casos por serogrupo C se relaciona con la elevada cobertura de la vacuna MenCC en nuestro entorno<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">La forma cl&#237;nica m&#225;s frecuente fue la sepsis&#44; pero en la literatura var&#237;a el predominio de sepsis o de meningitis seg&#250;n estudios<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;21</span></a>&#46; Los casos de sepsis y sepsis-meningitis consultaron antes que otras formas de enfermedad&#44; probablemente por la rapidez y la gravedad con la que evolucionan&#46; La fiebre y el exantema&#44; s&#237;ntomas habitualmente descritos en los casos<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">15&#44;21&#44;22</span></a>&#44; fueron las manifestaciones m&#225;s frecuentes al diagn&#243;stico&#46; En 2 de cada 10 pacientes el exantema no fue hemorr&#225;gico&#44; dato que resulta relevante<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a>&#44; porque&#44; frecuentemente&#44; infecciones menos graves en ni&#241;os se manifiestan de esta manera&#46; Como en otros estudios<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a>&#44; un elevado porcentaje de casos presentaba alg&#250;n signo de shock a su llegada al hospital&#46; Este hecho es destacable&#44; ya que algunos de estos signos se presentan precozmente<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a>&#44; y saber reconocerlos es importante para realizar un diagn&#243;stico temprano<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;12</span></a>&#46; En casi uno de cada 2 casos de sepsis-meningitis o meningitis&#44; los signos men&#237;ngeos fueron negativos&#44; posiblemente porque aparecen m&#225;s tard&#237;amente o porque en lactantes a menudo son negativos<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">7&#44;11</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Las alteraciones anal&#237;ticas encontradas son concordantes con lo publicado<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">15&#44;23</span></a>&#46; El porcentaje de casos con la PCT elevada fue superior al de casos con elevaci&#243;n de la prote&#237;na C reactiva&#46; Este hecho puede relacionarse con la corta evoluci&#243;n cl&#237;nica de la mayor&#237;a de casos y apoya la idea de que&#44; por su elevaci&#243;n precoz<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">24</span></a>&#44; la PCT resulta m&#225;s &#250;til en el diagn&#243;stico de la enfermedad<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">25</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">En la EMI se produce una activaci&#243;n masiva de la cascada inflamatoria y del sistema de la coagulaci&#243;n&#44; induci&#233;ndose da&#241;os en los &#243;rganos internos de los pacientes<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a>&#46; La gravedad de la enfermedad se refleja en el porcentaje de ingresos en UCIP y en la necesidad de medidas terap&#233;uticas de soporte&#46; Nuestros resultados coinciden con los de otros autores en letalidad&#44; mortalidad y media de estancia hospitalaria<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a>&#44; en que la mayor&#237;a de los casos que fallecen lo hacen en las primeras 24 h<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;21</span></a>&#44; y en la frecuencia y tipos de secuelas encontradas<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">8&#44;9</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Numerosos trabajos han analizado posibles marcadores pron&#243;sticos cl&#237;nicos y anal&#237;ticos en la EMI&#44; aislados o en forma de escalas<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">16&#44;26-32</span></a>&#46; En nuestro estudio&#44; la sepsis sin meningitis&#44; la convulsi&#243;n y la puntuaci&#243;n en la escala de coma de Glasgow &#60; 15 fueron los factores cl&#237;nicos que mostraron mayor valor para predecir un mal pron&#243;stico&#46; El tiempo de evoluci&#243;n de los s&#237;ntomas no mostr&#243; una asociaci&#243;n significativa con tener una mala evoluci&#243;n&#44; probablemente porque los casos m&#225;s graves tienden a consultar antes y compensan su peor pron&#243;stico inicial con un tratamiento m&#225;s temprano&#46; La presencia de un exantema extenso o evolucionado&#44; con nuestros datos&#44; tampoco alcanz&#243; la significaci&#243;n estad&#237;stica&#44; pero s&#237; se considera relevante para el pron&#243;stico<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">7&#44;30&#44;33</span></a>&#46; La trombocitopenia y la CID fueron los factores anal&#237;ticos que mostraron mejor capacidad para predecir un mal pron&#243;stico&#46; Este es un hecho relevante&#44; ya que el recuento de plaquetas es una determinaci&#243;n accesible&#44; poco costosa y que ha demostrado valor pron&#243;stico<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a>&#44; emple&#225;ndose en escalas compuestas como la del PN<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">En los protocolos de manejo del paciente pedi&#225;trico con EMI&#44; la trombocitopenia puede servir como un indicador de peor pron&#243;stico y ser especialmente &#250;til en centros que no dispongan de marcadores anal&#237;ticos m&#225;s sofisticados&#46; Los ni&#241;os con esta alteraci&#243;n anal&#237;tica&#44; u otras compatibles con CID&#44; as&#237; como los que presenten sepsis sin meningitis&#44; una puntuaci&#243;n en la escala de coma de Glasgow<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>15 o una convulsi&#243;n&#44; deber&#237;an ser considerados de alto riesgo&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Los resultados de este trabajo deben de ser interpretados en el contexto de sus limitaciones&#46; Aunque el estudio englob&#243; todos los casos de EMI en Navarra&#44; el tama&#241;o muestral fue peque&#241;o y se limit&#243; a una zona geogr&#225;fica concreta&#46; La recogida retrospectiva de los datos pudo inducir sesgos&#46; No se tuvo en cuenta si los casos hab&#237;an consultado con anterioridad en su centro de atenci&#243;n primaria&#44; ni se recogieron otros s&#237;ntomas como cefalea&#44; v&#243;mitos o fotofobia<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">15&#44;21</span></a>&#46; No se pudieron determinar los par&#225;metros anal&#237;ticos en todos los pacientes&#46; En algunos de los casos con secuelas permanentes o muerte&#44; no se dispuso de los valores de PCT&#44; EB y leucocitos en el l&#237;quido cefalorraqu&#237;deo&#44; por lo que la asociaci&#243;n de estos par&#225;metros con un mal desenlace podr&#237;a ser mayor a la encontrada&#46; Adem&#225;s&#44; en la mayor&#237;a de los casos&#44; el EB se determin&#243; en sangre venosa y la presencia de CID&#44; al recogerse en un momento m&#225;s avanzado de la enfermedad&#44; pudo tener cierta ventaja sobre otros factores&#46; No se recogieron las secuelas psicol&#243;gicas&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">En Espa&#241;a&#44; con la reciente comercializaci&#243;n de la vacuna frente al meningococo B&#44; se inicia una nueva era en la prevenci&#243;n de la EMI&#46; Ante este nuevo escenario&#44; es probable que se sucedan cambios en esta enfermedad en un futuro pr&#243;ximo&#44; por lo que la situaci&#243;n descrita es el punto de partida para nuevos estudios que eval&#250;en en los pr&#243;ximos a&#241;os el impacto de la nueva vacuna&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Como conclusi&#243;n&#44; pese a los importantes avances realizados en la prevenci&#243;n de EMI mediante la vacunaci&#243;n universal frente al meningococo C en la infancia&#44; la enfermedad contin&#250;a siendo un grave problema de salud infantil&#46; El reconocimiento precoz de los s&#237;ntomas&#44; la optimizaci&#243;n del tratamiento inicial en los servicios de urgencias y el trasladado urgente de los pacientes a centros que dispongan de una UCIP son estrategias fundamentales para conseguir disminuir la mortalidad y las secuelas de la enfermedad&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicto de intereses</span><p id="par0165" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => "Abstract"
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              "titulo" => "Introduction"
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            1 => "Epidemiolog&#237;a"
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            3 => "Factores pron&#243;sticos"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" 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="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" 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="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" 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="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" 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>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" 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="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and methods</span><p id="spar0030" 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="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The average annual incidence was 7&#46;9 cases per 100&#44;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&#160;&#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>&#160;10&#46;9&#41; showed a greater association with a worse prognosis&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" 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>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Un caso falleci&#243; al ingreso en el hospital&#44; por lo que no se obtuvieron datos anal&#237;ticos&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La determinaci&#243;n de procalcitonina se inici&#243; en 2009&#46;</p>"
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                  \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">Manifestaciones cl&#237;nicas&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&#44; N&#46;&#176;&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">Hallazgo presente<br>N&#46;&#176; &#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">Temperatura axilar &#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>Temperatura axilar &#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">Exantema</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">Exantema hemorr&#225;gico&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">Signos de 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">Puntuaci&#243;n escala de coma de Glasgow &#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">Convulsi&#243;n</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="char" valign="top"><span class="elsevierStyleItalic">Par&#225;metros anal&#237;ticos en sangre</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>Procalcitonina &#62; 0&#44;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>Leucocitos &#62; 10&#46;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>Exceso de base &#60; &#8211;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>Leucocitos polimorfonucleares &#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>Prote&#237;na C reactiva &#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>Plaquetas &#60; 150&#46;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>Leucocitos &#60; 4&#46;500&#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>Neutr&#243;filos &#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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        "descripcion" => array:1 [
          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Hallazgos cl&#237;nicos y anal&#237;ticos presentes al diagn&#243;stico en pacientes menores de 15 a&#241;os con enfermedad meningoc&#243;cica invasiva en Navarra&#44; 2008-2014</p>"
        ]
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        "etiqueta" => "Tabla 2"
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        "mostrarDisplay" => false
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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">Factores cl&#237;nicos&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 N&#46;&#176;&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">Mala evoluci&#243;n<br>N&#46;&#176; &#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">Odds ratio cruda &#40;intervalo de confianza del 95&#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">p<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 sin 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="left" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;6&#44;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>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;38&#44;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">9&#44;1 &#40;1&#44;5-78&#44;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">0&#44;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">Sepsis grave</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="left" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;5&#44;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>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;20&#44;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">4&#44;1 &#40;0&#44;5-102&#44;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">0&#44;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">Lesiones cut&#225;neas extensas&#47;evolucionadas</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="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;4&#44;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">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>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;26&#44;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">7&#44;5 &#40;1&#44;0-187&#44;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">0&#44;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">Puntuaci&#243;n escala de coma de Glasgow &#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="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;4&#44;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">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>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;28&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#44;2 &#40;1&#44;2-230&#44;6&#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&#44;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">Evoluci&#243;n</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 h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;10&#44;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">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>12-23 h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;18&#44;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">2&#44;0 &#40;0&#44;2-4&#44;6&#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&#44;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 h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;14&#44;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">1&#44;5 &#40;0&#44;1-19&#44;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&#44;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">Convulsi&#243;n</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="left" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;10&#44;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">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>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;50&#44;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">8&#44;3 &#40;1&#44;1-65&#44;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">0&#44;040&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">p obtenida por el m&#233;todo exacto de Fisher a 2 colas&#46;</p>"
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        "descripcion" => array:1 [
          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Factores cl&#237;nicos asociados a la mala evoluci&#243;n en pacientes menores de 15 a&#241;os con enfermedad meningoc&#243;cica invasiva en Navarra&#44; 2008-2014</p>"
        ]
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      3 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Tabla 3"
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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">Factores anal&#237;ticos &#40;en sangre&#44; excepto el &#250;ltimo&#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<br>N&#46;&#176;&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">Mala evoluci&#243;n<br>N&#46;&#176; &#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">Odds ratio cruda &#40;intervalo de confianza del 95&#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">p<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">Leucocitos &#60; 4&#46;500&#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="left" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;12&#44;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>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;25&#44;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&#44;3 &#40;0&#44;1-27&#44;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&#44;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">Neutr&#243;filos &#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="left" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;11&#44;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>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;33&#44;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&#44;6 &#40;0&#44;1-54&#44;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">0&#44;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">Plaquetas &#60; 150&#46;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="left" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;5&#44;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>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;66&#44;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&#44;5 &#40;3&#44;6-377&#44;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">0&#44;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">Procalcitonina &#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="left" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;3&#44;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>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;40&#44;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&#44;7 &#40;0&#44;9-526&#44;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">0&#44;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">Coagulaci&#243;n intravascular diseminada</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="left" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;7&#44;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>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;50&#44;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">10&#44;9 &#40;1&#44;4-94&#44;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">0&#44;025&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">Exceso bases &#60; &#8211;8</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="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;6&#44;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>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;25&#44;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">4&#44;5 &#40;0&#44;1-206&#44;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">0&#44;400&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">Producto plaquetas x neutr&#243;filos &#60; 40</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">10</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">9</span></span><span class="elsevierStyleItalic">&#47;L</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="left" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;11&#44;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>S&#237;&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="left" valign="top">1 &#40;100&#44;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">No disponible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;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">Leucocitos en l&#237;quido cefalorraqu&#237;deo &#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="left" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;10&#44;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>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&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&#44;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&#44;0-34&#44;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">0&#44;808&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Factores anal&#237;ticos asociados a la mala evoluci&#243;n en pacientes menores de 15 a&#241;os con enfermedad meningoc&#243;cica invasiva en Navarra&#44; 2008-2014</p>"
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    "bibliografia" => array:2 [
      "titulo" => "Bibliograf&#237;a"
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              "identificador" => "bib0170"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Global epidemiology of meningococcal disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46;H&#46; Harrison"
                            1 => "C&#46;L&#46; Trotter"
                            2 => "M&#46;E&#46; Ramsay"
                          ]
                        ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.vaccine.2009.04.063"
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                        "tituloSerie" => "Vaccine"
                        "fecha" => "2009"
                        "volumen" => "27"
                        "numero" => "Suppl 2"
                        "paginaInicial" => "B51"
                        "paginaFinal" => "B63"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19477562"
                            "web" => "Medline"
                          ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Meningococcal disease"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "N&#46;E&#46; Rosenstein"
                            1 => "B&#46;A&#46; Perkins"
                            2 => "D&#46;S&#46; Stephens"
                            3 => "T&#46; Popovic"
                            4 => "J&#46;M&#46; Hughes"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM200105033441807"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med&#46;"
                        "fecha" => "2001"
                        "volumen" => "344"
                        "paginaInicial" => "1378"
                        "paginaFinal" => "1388"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11333996"
                            "web" => "Medline"
                          ]
                        ]
                      ]
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              "identificador" => "bib0180"
              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemic meningitis&#44; meningococcaemia&#44; and <span class="elsevierStyleItalic">Neisseria meningitidis</span>"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46;S&#46; Stephens"
                            1 => "B&#46; Greenwood"
                            2 => "P&#46; Brandtzaeg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(07)61016-2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet&#46;"
                        "fecha" => "2007"
                        "volumen" => "369"
                        "paginaInicial" => "2196"
                        "paginaFinal" => "2210"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17604802"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#91;Invasive meningococcal disease&#93;"
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                          "autores" => array:2 [
                            0 => "J&#46;A&#46; Soult Rubio"
                            1 => "M&#46; Munoz Saez"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "An Pediatr &#40;Barc&#41;&#46;"
                        "fecha" => "2005"
                        "volumen" => "62"
                        "paginaInicial" => "297"
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