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        "titulo" => "Use of antihyperglycaemic therapy with cardiovascular benefit in patients with type 2 diabetes who require hospitalisation&#58; A cross-sectional study"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flujo de pacientes que recibieron tratamiento con iSGLT2&#46;</p>"
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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">Recientemente se ha producido un gran cambio en las gu&#237;as de pr&#225;ctica cl&#237;nica de tratamiento de los pacientes con diabetes tipo 2<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a>&#46; Es una consecuencia de los estudios de seguridad cardiovascular llevados a cabo con f&#225;rmacos inhibidores del cotransportador 2 de sodio-glucosa &#40;iSGLT2&#41; y de agonistas del receptor del p&#233;ptido similar al glucag&#243;n de tipo 1 &#40;AR-GLP1&#41;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2&#8211;6</span></a>&#46; Empagliflozina&#44; canagliflozina y dapagliflozina son iSGLT2 que han demostrado reducir el objetivo compuesto por muerte de causa cardiovascular&#44; infarto de miocardio o accidente cerebrovascular no mortales &#40;desenlace denominado MACE&#41;&#44; con respecto a otros tratamientos de la diabetes&#59; asimismo&#44; tambi&#233;n han mostrado reducir el da&#241;o renal y el riesgo de descompensaci&#243;n por insuficiencia cardiaca<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2&#8211;4</span></a>&#46; En el caso de los f&#225;rmacos AR-GLP1&#44; tanto liraglutida como semaglutida han demostrado beneficio cardiovascular al reducir el desenlace combinado MACE<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">5&#44;6</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Para pacientes con enfermedad cardiovascular cl&#237;nica se recomienda que el tratamiento incluya un iSGLT2 o un GLP-1&#46; Para pacientes con enfermedad renal cr&#243;nica o insuficiencia cardiaca cl&#237;nica y enfermedad cardiovascular ateroscler&#243;tica se recomienda que el tratamiento incluya un inhibidor de SGLT2&#46; Dentro del algoritmo de tratamiento los AR-GLP-1 se recomiendan ahora como el primer medicamento inyectable que se ha de utilizar si el paciente no alcanza los objetivos de control gluc&#233;mico&#44; y siempre que no exista hiperglucemia sintom&#225;tica&#44; en cuyo caso es aconsejable el uso de insulina&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Sin embargo&#44; los ensayos cl&#237;nicos de seguridad cardiovascular con f&#225;rmacos antihiperglucemiantes incluyen una poblaci&#243;n en la que habitualmente est&#225;n infrarrepresentados pacientes de edad avanzada &#40;como aquellos mayores de 75 a&#241;os&#41;&#44; pacientes fr&#225;giles o con comorbilidades severas&#46; En Espa&#241;a&#44; uno de los pa&#237;ses de mayor longevidad&#44; la prevalencia de diabetes tipo 2 en pacientes mayores de 75 a&#241;os de edad alcanza el 23&#37;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a>&#46; Los estudios realizados en vida real muestran que solo un 15&#44;7&#37; de los pacientes con diabetes presentan un riesgo cardiovascular similar a los pacientes incluidos en alguno de los estudios de seguridad cardiovascular<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a>&#46; Respecto a los pacientes con diabetes tipo 2 que ingresan en el hospital&#44; su edad media es de 73 a&#241;os&#44; presentando un 40&#37; enfermedad cardiovascular establecida<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a>&#46; La insuficiencia renal cr&#243;nica es otro de los factores de riesgo altamente prevalentes en los pacientes con diabetes y que condiciona el pron&#243;stico cardiovascular&#46; Los estudios llevados a cabo en pacientes con diabetes en Espa&#241;a muestran una prevalencia de reducci&#243;n de filtrado glomerular inferior a 60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> del 28&#37;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a>&#59; sin embargo&#44; en la poblaci&#243;n con diabetes tipo 2 esta proporci&#243;n puede alcanzar el 55&#37;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Dado que los pacientes con diabetes que ingresan en los servicios de medicina interna constituyen una poblaci&#243;n de muy alto riesgo cardiovascular&#44; en el presente estudio nos planteamos como objetivo conocer el uso de terapias antihiperglucemiantes con beneficio cardiovascular&#46; As&#237; mismo&#44; estudiamos los posibles determinantes en la elecci&#243;n de la terapia con beneficio cardiovascular&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Estudio observacional-transversal basado en la revisi&#243;n de las historias cl&#237;nicas&#46; El estudio fue aprobado por el Comit&#233; de Investigaci&#243;n del Hospital Marina Baixa &#40;Villajoyosa&#44; Alicante&#41;&#46; Hemos seguido las recomendaciones STROBE para la elaboraci&#243;n del presente estudio transversal<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a>&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio</span><p id="par0030" class="elsevierStylePara elsevierViewall">Se prepar&#243; un cuestionario para recoger los h&#225;bitos de prescripci&#243;n de f&#225;rmacos antihiperglucemiantes en pacientes hospitalizados en servicios de medicina interna&#46; La recogida de datos se llev&#243; a cabo en un d&#237;a determinado entre el 20 de mayo y el 7 de junio del a&#241;o 2019&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Poblaci&#243;n de estudio</span><p id="par0035" class="elsevierStylePara elsevierViewall">Se incluyeron los pacientes con diabetes tipo 2 hospitalizados durante el periodo de estudio en los servicios de medicina interna de hospitales espa&#241;oles&#46; Este cuestionario an&#243;nimo recogi&#243; informaci&#243;n en relaci&#243;n con las siguientes variables&#58; datos demogr&#225;ficos&#44; datos antropom&#233;tricos&#44; datos de laboratorio&#44; valoraci&#243;n de la fragilidad y del deterioro cognitivo&#44; prescripci&#243;n de f&#225;rmacos antihiperglucemiantes y dosis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Desenlace primario</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">S</span>e defini&#243; como desenlace primario la utilizaci&#243;n de f&#225;rmacos iSGLT2 y AR-GLP1 en pacientes de muy alto riesgo cardiovascular&#44; o con insuficiencia cardiaca de acuerdo a las indicaciones seg&#250;n la ficha t&#233;cnica del producto y las condiciones de financiaci&#243;n del Sistema Nacional de Salud&#46; En Espa&#241;a la financiaci&#243;n de f&#225;rmacos iSGLT2 est&#225; reservada para pacientes con diabetes tipo 2 que presentan filtrado glomerular superior a 45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#59; por otro lado la financiaci&#243;n de f&#225;rmacos AR-GLP1 est&#225; reservada a pacientes con diabetes tipo 2 con &#237;ndice de masa corporal superior a 30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> y que presenten un filtrado glomerular superior a 15<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Definiciones</span><p id="par0045" class="elsevierStylePara elsevierViewall">Fragilidad&#58; se defini&#243; como pacientes fr&#225;giles a aquellos incluidos en los grupos 5 a 9 en la escala de fragilidad de Rockwood<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Insuficiencia renal&#58; se defini&#243; la presencia de insuficiencia renal seg&#250;n los criterios de KDIGO 2012 y se clasific&#243; en funci&#243;n del grado de filtrado glomerular estimado y el grado de proteinuria medido en una muestra aislada de orina recogida por la ma&#241;ana<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a>&#46; Los valores de creatinina&#44; filtrado glomerular estimado y cociente albuminuria&#47;creatinina se recogieron en la historia cl&#237;nica con el paciente en situaci&#243;n estable previo al ingreso en el hospital&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Muy alto riesgo cardiovascular&#58; se defini&#243; como pacientes con muy alto riesgo cardiovascular a aquellos que ten&#237;an historia cl&#237;nica previa de infarto agudo de miocardio&#44; s&#237;ndrome coronario agudo&#44; accidente cerebrovascular o accidente isqu&#233;mico transitorio&#44; procedimientos de revascularizaci&#243;n coronaria&#44; aneurisma de aorta y enfermedad arterial perif&#233;rica&#46; Tambi&#233;n se incluyeron en este grupo a aquellos pacientes con diabetes tipo 2 y proteinuria&#44; as&#237; como a los pacientes con un filtrado glomerular mantenido inferior a 30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; es decir&#44; los que ten&#237;an una enfermedad renal cr&#243;nica<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Riesgo de sesgo</span><p id="par0060" class="elsevierStylePara elsevierViewall">Se remiti&#243; el cuestionario a los miembros del Grupo de Estudio de Diabetes&#44; Obesidad y Nutrici&#243;n de la Sociedad Espa&#241;ola de Medicina Interna&#44; siendo su participaci&#243;n voluntaria en la recogida de datos&#46; La muestra final cont&#243; con la participaci&#243;n de 73 investigadores &#40;10&#44;6&#37;&#41; de un total de 684 miembros pertenecientes al grupo de estudio&#46; El riesgo de sesgo se estim&#243; como peque&#241;o&#44; ya que el estudio recogi&#243; datos sobre prescripci&#243;n de antihiperglucemiantes de los pacientes previo a su ingreso en el hospital&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Tama&#241;o muestral</span><p id="par0065" class="elsevierStylePara elsevierViewall">Seg&#250;n los datos de la literatura la poblaci&#243;n de pacientes con diabetes tipo 2 de muy alto riesgo cardiovascular de edad superior a 70 a&#241;os que ser&#237;a elegible para tratamiento con iSGLT2 o AR-GLP1 se sit&#250;a entre el 25-40&#37;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a>&#46; Un intervalo de confianza del 95&#37; con una precisi&#243;n de<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#37; proporciona un tama&#241;o muestral efectivo de n<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>369&#46; La prevalencia de disminuci&#243;n del filtrado glomerular o la presencia de proteinuria en pacientes con diabetes tipo 2 en Espa&#241;a se sit&#250;a en el 35&#37;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a>&#58; en pacientes con diabetes tipo 2 hospitalizados la proporci&#243;n de pacientes con filtrado glomerular inferior a 60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> alcanz&#243; el 55&#37; en un amplio estudio transversal llevado a cabo en Espa&#241;a<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a>&#46; Un intervalo de confianza al 95&#37; con una precisi&#243;n de<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#37; proporciona un tama&#241;o muestral efectivo de n<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>381&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">An&#225;lisis estad&#237;stico</span><p id="par0070" class="elsevierStylePara elsevierViewall">Los datos categ&#243;ricos se presentan como n&#250;meros y porcentajes&#59; los datos continuos con distribuci&#243;n normal como media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desviaci&#243;n est&#225;ndar &#40;DE&#41; y las variables continuas no distribuidas normalmente como mediana y rango intercuart&#237;lico &#40;IQR&#41;&#46; El an&#225;lisis de varianza de una v&#237;a &#40;ANOVA&#41; y las pruebas de Kruskal-Wallis se utilizaron para comparar las variables continuas entre los grupos en funci&#243;n de la normalidad de la distribuci&#243;n&#44; y la prueba de la Chi cuadrado se utiliz&#243; para las variables categ&#243;ricas&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Se llev&#243; a cabo un an&#225;lisis de regresi&#243;n log&#237;stica para identificar los determinantes asociados con el uso de f&#225;rmacos iSGLT2 y AR-GLP1 seg&#250;n las condiciones de financiaci&#243;n de nuestro Sistema Nacional de Salud&#46; Se llevaron a cabo 2 modelos estad&#237;sticos&#44; uno cuya variable respuesta fue la presencia de iSGLT2 en el tratamiento de la diabetes antes del ingreso&#44; y otro en el que la variable respuesta fue el uso de AR-GLP1 en el tratamiento de la diabetes antes del ingreso&#46; Como variables independientes se consideraron aquellas que en el an&#225;lisis univariante presentaban una asociaci&#243;n con un valor de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;10&#46; Todos los an&#225;lisis se realizaron utilizando el software SPSS &#40;v&#46;22&#41;&#46; Se consider&#243; un valor p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 como estad&#237;sticamente significativo&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Requerimientos &#233;ticos y legales</span><p id="par0080" class="elsevierStylePara elsevierViewall">Todos los datos se han anonimizado en su punto de extracci&#243;n&#46; La informaci&#243;n no cl&#237;nicamente identificable se puso a disposici&#243;n de los investigadores&#46; El estudio lo aprob&#243; el Comit&#233; de Investigaci&#243;n del Hospital Marina Baixa y se clasific&#243; como una auditor&#237;a de la pr&#225;ctica actual en comparaci&#243;n con la mejor evidencia disponible&#44; por lo que no se consider&#243; necesario el consentimiento informado de los pacientes&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Resultados</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Participantes</span><p id="par0085" class="elsevierStylePara elsevierViewall">Participaron en la recogida de datos 74 hospitales de un total de 224 pertenecientes al Sistema Nacional de Salud&#44; lo que representa una proporci&#243;n del 34&#37; &#40;intervalo de confianza al 95&#37; &#91;IC 95&#37;&#93;&#58; 28&#44;0-40&#44;3&#37;&#41;&#46; En el periodo de estudio se encontraban ingresados en los servicios de medicina interna un total de 3&#46;290 pacientes&#44; de los cuales 908 &#40;27&#44;6&#37;&#41; ten&#237;an diabetes mellitus como diagn&#243;stico primario o secundario&#46; El principal motivo de ingreso de los pacientes en los servicios de medicina interna fue por una enfermedad infecciosa &#40;46&#37;&#41; o una enfermedad cardiovascular &#40;34&#44;5&#37;&#41;&#46; Solo un 6&#44;4&#37; de los ingresos estuvo relacionado con descompensaciones gluc&#233;micas como diagn&#243;stico primario&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Datos descriptivos</span><p id="par0090" class="elsevierStylePara elsevierViewall">Los pacientes incluidos en el estudio ten&#237;an una edad media de 78&#44;9 a&#241;os&#44; con una duraci&#243;n mediana de la diabetes desde el diagn&#243;stico de 11 a&#241;os &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 1</a>&#41;&#46; El &#237;ndice de masa corporal medio fue de 29&#46; Un 60&#37; ten&#237;a enfermedad cardiovascular establecida&#44; definida por antecedentes de enfermedad coronaria &#40;27&#37;&#41;&#44; enfermedad cerebrovascular &#40;20&#44;4&#37;&#41; o enfermedad arterial perif&#233;rica &#40;13&#44;9&#37;&#41;&#59; aproximadamente una tercera parte de los pacientes hab&#237;a presentado un episodio de insuficiencia cardiaca previo&#46; La media de filtrado glomerular estimado fue de 56&#44;4<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#46; El grado de control gluc&#233;mico medido por el valor de HbA1c &#40;HbA1c<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8&#37;&#41; fue aceptable en el 62&#44;7&#37; de los pacientes&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Respecto al uso de terapias antihiperglucemiantes&#44; los f&#225;rmacos m&#225;s utilizados fueron metformina &#40;49&#44;1&#37;&#41;&#44; iDPP4 &#40;39&#37;&#41; e insulina &#40;35&#44;2&#37;&#41;&#46; El uso de iSGLT2 y AR-GLP1 estuvo en 5&#44;8&#37; y 2&#44;6&#37;&#44; respectivamente&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">El uso de las principales terapias para enfermedad cardiovascular fue de antiagregantes plaquetarios &#40;40&#44;1&#37;&#41;&#44; IECAS &#40;27&#44;6&#37;&#41;&#44; ARA-II &#40;27&#44;7&#37;&#41;&#44; bloqueadores beta &#40;36&#44;2&#37;&#41;&#44; diur&#233;ticos &#40;46&#37;&#41; y estatinas o ezetimiba &#40;53&#44;9&#37;&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Desenlaces medidos</span><p id="par0105" class="elsevierStylePara elsevierViewall">Un total de 547 &#40;60&#44;4&#37;&#41; pacientes mostraban valores de filtrado glomerular estimado por la f&#243;rmula CKD-EPI superiores a 45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; l&#237;mite establecido para la financiaci&#243;n de la prescripci&#243;n de f&#225;rmacos iSGLT2 en nuestro pa&#237;s&#46; Entre estos pacientes&#44; 65 &#40;12&#44;2&#37;&#41; presentaban como contraindicaci&#243;n para el uso de iSGLT2 la presencia de enfermedad arterial perif&#233;rica&#46; La distribuci&#243;n de uso de iSGLT2 en pacientes de muy alto riesgo de enfermedad cardiovascular&#44; definido por enfermedad coronaria&#44; enfermedad cerebrovascular&#44; enfermedad renal cr&#243;nica e insuficiencia cardiaca congestiva fue inferior al 10&#37; en todos los casos &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Un total de 286 pacientes presentaba obesidad definida por un &#237;ndice de masa corporal superior a 30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; l&#237;mite estimado para la financiaci&#243;n de tratamiento con AR-GLP1 en nuestro pa&#237;s&#46; Debido al escaso n&#250;mero de observaciones han sido agrupados los AR-GLP1 con mostrado beneficio cardiovascular &#40;liraglutida y semaglutida&#41; con aquellos que presentan seguridad cardiovascular &#40;exenatida de larga acci&#243;n&#44; lixisenatida y albiglutida&#41;&#46; La distribuci&#243;n de uso de AR-GLP1 en pacientes de muy alto riesgo cardiovascular se situ&#243; en un valor m&#225;ximo del 6&#44;4&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Determinantes de utilizaci&#243;n de inhibidores del cotransportador sodio-glucosa 2</span><p id="par0115" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 2</a> muestra la asociaci&#243;n entre la utilizaci&#243;n de tratamiento con iSGLT2 y diversas variables demogr&#225;ficas y epidemiol&#243;gicas en individuos que presentaban un filtrado glomerular estimado superior a 45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>548&#41;&#46; En el an&#225;lisis univariante encontramos una asociaci&#243;n estad&#237;sticamente significativa entre la prescripci&#243;n de iSGLT2 y la edad&#44; el &#237;ndice de masa corporal y el grado de dependencia&#46; La presencia de enfermedad cardiovascular y enfermedad renal cr&#243;nica&#44; los antecedentes de insuficiencia cardiaca&#44; el sexo var&#243;n&#44; la presencia de demencia o los valores de hemoglobina glucosilada no se asociaron con el uso de iSGLT2 previo al ingreso hospitalario&#46; En el an&#225;lisis multivariante los pacientes mayores de 75 a&#241;os de edad mostraron un menor uso de f&#225;rmacos iSGLT2 con respecto a los pacientes menores de 65 a&#241;os &#40;<span class="elsevierStyleItalic">odds ratio</span> ajustada&#58; 0&#44;28&#59; IC 95&#37;&#58; 0&#44;10-0&#44;74&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;039&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Determinantes de utilizaci&#243;n de agonistas del receptor del p&#233;ptido similar al glucag&#243;n tipo 1</span><p id="par0120" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 3</a> muestra la asociaci&#243;n entre la utilizaci&#243;n de tratamiento con AR-GLP1 y diversas variables demogr&#225;ficas y epidemiol&#243;gicas en individuos que presentaban un &#237;ndice de masa corporal mayor de 30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>302&#41;&#46; En el an&#225;lisis univariante encontramos una asociaci&#243;n estad&#237;sticamente significativa entre la prescripci&#243;n de AR-GLP1&#44; la edad y el filtrado glomerular estimado&#46; El grado de dependencia&#44; la presencia de enfermedad cardiovascular&#44; los antecedentes de insuficiencia cardiaca&#44; el sexo var&#243;n&#44; la presencia de demencia o los valores de hemoglobina glucosilada no se asociaron con el uso de AR-GLP1 previo al ingreso hospitalario&#46; En el an&#225;lisis multivariante solo la edad mantuvo la significaci&#243;n estad&#237;stica&#46; Los pacientes de m&#225;s de 75 a&#241;os de edad tuvieron un menor uso de f&#225;rmacos AR-GLP1 con respecto a los pacientes menores de 65 a&#241;os &#40;<span class="elsevierStyleItalic">odds ratio</span> ajustada&#58; 0&#44;09&#59; IC 95&#37;&#58; 0&#44;02-0&#44;46&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;006&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Discusi&#243;n</span><p id="par0125" class="elsevierStylePara elsevierViewall">El presente estudio muestra que una elevada proporci&#243;n de pacientes con diabetes mellitus tipo 2 ingresados en los servicios de medicina interna de hospitales espa&#241;oles presenta muy alto riesgo cardiovascular&#46; Espec&#237;ficamente un 35&#37; de los pacientes ingresaron debido a la presencia de enfermedad cardiovascular como diagn&#243;stico principal&#44; siendo las enfermedades de base m&#225;s frecuentes la enfermedad cardiovascular establecida en el 60&#37; de los pacientes o la enfermedad renal cr&#243;nica en el 54&#37;&#46; Un 32&#37; de los pacientes hab&#237;a presentado con anterioridad al menos un episodio de insuficiencia cardiaca&#46; A pesar del elevado riesgo cardiovascular de los pacientes&#44; el uso previo al ingreso de f&#225;rmacos antihiperglucemiantes con beneficio cardiovascular ha sido escaso&#46; En concreto&#44; el uso de iSGLT2 fue inferior al 6&#37; de la poblaci&#243;n y el uso de AR-GLP1 no alcanz&#243; el 3&#37; de los pacientes&#46; El an&#225;lisis de los determinantes de uso mostr&#243; que la prescripci&#243;n de iSGLT2 se asoci&#243; con un mayor &#237;ndice de masa corporal o un menor grado de dependencia para las actividades de la vida diaria&#44; mientras que la utilizaci&#243;n de f&#225;rmacos AR-GLP1 se asoci&#243; con un menor rango de edad y una menor tasa de filtrado glomerular estimado&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Solo un 60&#37; de pacientes con filtrado glomerular superior 30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> recib&#237;a tratamiento con metformina&#44; mientras que en los estudios de seguridad cardiovascular con empagliflozina&#44; canagliflozina y dapaglifozina el porcentaje se situ&#243; entre el 73-80&#37;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2&#8211;4</span></a>&#46; Una hip&#243;tesis que podr&#237;a explicar este hecho es que la metformina comercializada en los pa&#237;ses anglosajones y EE&#46; UU&#46; es una formulaci&#243;n de liberaci&#243;n prologanda con mejor tolerabilidad digestiva y mayor coste&#46; La escasa utilizaci&#243;n de f&#225;rmacos antihiperglucemiantes con beneficio cardiovascular se ha confirmado tambi&#233;n en otros estudios&#46; En el estudio llevado a cabo por Fadini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> la utilizaci&#243;n de iSGLT2 fue del 1&#44;8&#37;&#44; y de AR-GLP1 fue del 3&#44;9&#37; en un total de 563 pacientes&#44; con una edad media de 69 a&#241;os y enfermedad cardiovascular reciente que tuvieron un primer seguimiento en consulta&#46; Tras sufrir el evento cardiovascular se produjeron incrementos en la prescripci&#243;n de estatinas&#44; IECA&#44; ARA-II&#44; diur&#233;ticos y antiagregantes plaquetarios&#44; pero no surgieron cambios apreciables en la prescripci&#243;n de iSGLT2 y AR-GLP1&#46; Incluso en los pacientes con enfermedad cardiovascular establecida el uso de otros f&#225;rmacos&#44; tales como antiagregantes&#44; estatinas&#44; IECA&#44; ARA-II y ARNI presentaron un amplio margen de mejora&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Al contrario que en el estudio aludido&#44; nuestros pacientes presentaban una edad media de 79 a&#241;os y un mayor grado de dependencia para las actividades de la vida diaria&#59; posiblemente estos factores justifiquen la utilizaci&#243;n de f&#225;rmacos con mejor perfil de tolerabilidad como son los iDPP4 y la metformina&#46; Existen algunos estudios que muestran la eficacia y seguridad de iSGLT2 y AR-GLP1 utilizados en combinaci&#243;n en pacientes con edad avanzada con importante comorbilidad<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a>&#44; pero la experiencia cl&#237;nica a&#250;n es escasa&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Entre las limitaciones&#44; como en todo estudio retrospectivo&#44; debemos destacar que hubo defectos en la recogida de algunos datos por falta de disponibilidad<span class="elsevierStyleBold">&#46;</span> Tampoco disponemos de informaci&#243;n de los m&#233;dicos prescriptores&#44; por lo que desconocemos el grado de adherencia a las gu&#237;as de pr&#225;ctica cl&#237;nica por especialidades&#44; lo que representa una limitaci&#243;n para poder introducir medidas educativas&#46; Por otro lado&#44; hay que tener en cuenta que el informe de posicionamiento terap&#233;utico recomienda precauci&#243;n en el tratamiento con iSGLT2 o AR-GLP1 en personas mayores de 75 a&#241;os debido a la escasa informaci&#243;n existente en la literatura&#46; La baja utilizaci&#243;n de f&#225;rmacos hipoglucemiantes con probado beneficio cardiovascular tambi&#233;n se puede explicar en relaci&#243;n con el decalaje habitual observado desde la inclusi&#243;n de las recomendaciones en las gu&#237;as de pr&#225;ctica cl&#237;nica hasta su implementaci&#243;n en la vida real<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a>&#46; Aunque la difusi&#243;n de las gu&#237;as de pr&#225;ctica cl&#237;nica acerca del tratamiento de la diabetes tipo 2 es amplia&#44; a trav&#233;s de sociedades cient&#237;ficas como la Asociaci&#243;n de Diabetes Americana&#44; la Sociedad Europea para el Estudio de la Diabetes o las gu&#237;as de la Sociedad Espa&#241;ola de Diabetes<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;19&#44;20</span></a>&#44; su implementaci&#243;n en la vida real puede verse dificultada por falta de conocimiento&#44; resistencia al cambio o por barreras organizativas o financieras<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">21&#8211;23</span></a>&#46; Como ejemplo&#44; en Europa la utilizaci&#243;n de f&#225;rmacos con reconocido beneficio sobre la nefropat&#237;a diab&#233;tica mostr&#243; una gran variaci&#243;n para el uso de f&#225;rmacos bloqueantes del sistema renina-angiotensina&#44; con valores entre el 74-84&#37;&#44; o el uso de estatinas en pacientes mayores de 40 a&#241;os&#44; con valores entre el 40&#37; al 83&#37;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a>&#46; Sin embargo&#44; en nuestro estudio es llamativo el muy bajo porcentaje de uso de iSGLT2 en pacientes con antecedentes de nefropat&#237;a diab&#233;tica&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Creemos que los resultados de nuestro estudio son generalizables y que en la poblaci&#243;n con elevada edad el uso de f&#225;rmacos antihiperglucemiantes con beneficio cardiovascular contin&#250;a siendo escaso&#46; Nuestros datos provienen de un total de 74 &#40;34&#37;&#41; hospitales pertenecientes al Sistema Nacional de Salud&#44; lo que representa un total de 3&#46;290 pacientes ingresados en los servicios de medicina interna en el momento del estudio&#46; La recogida de datos fue efectuada por miembros del Grupo de Estudio de Diabetes&#44; Obesidad y Nutrici&#243;n de la Sociedad de Medicina Interna&#44; con especial inter&#233;s en el estudio y control de la diabetes en pacientes en los servicios de medicina interna&#44; por lo que es posible que la inclusi&#243;n de otros hospitales quiz&#225;s hubiese significado una proporci&#243;n a&#250;n menor de uso de f&#225;rmacos antihiperglucemiantes con beneficio cardiovascular&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Las implicaciones de nuestro estudio son claras&#58; es preciso implementar el uso de tratamientos antihiperglucemiantes con probado beneficio cardiovascular en pacientes de alto riesgo&#46; Para ello ser&#237;an necesarios estudios en poblaciones habitualmente no representadas en los ensayos cl&#237;nicos&#44; como la poblaci&#243;n anciana&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Financiaci&#243;n</span><p id="par0155" class="elsevierStylePara elsevierViewall">Este estudio se ha llevado a cabo con una ayuda de fondos para investigaci&#243;n del Grupo de Trabajo de Diabetes&#44; Obesidad y Nutrici&#243;n de la Sociedad Espa&#241;ola de Medicina Interna&#46;</p></span><span id="sec1090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicto de intereses</span><p id="par0160" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluar el uso de la terapia con beneficio cardiovascular en pacientes con DM tipo 2 previo al ingreso en servicios de medicina interna&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal en un d&#237;a de los pacientes con DM tipo 2 hospitalizados en servicios de medicina interna&#46; Se recogieron variables demogr&#225;ficas y antropom&#233;tricas&#44; datos de laboratorio y utilizaci&#243;n de f&#225;rmacos antihiperglucemiantes&#46; La variable desenlace fue la proporci&#243;n y los determinantes de uso de inhibidores del cotransportador sodio-glucosa 2 &#40;iSGLT2&#41; y de agonistas del receptor del p&#233;ptido similar al glucag&#243;n tipo 1 &#40;AR-GLP1&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 928 pacientes pertenecientes a 74 hospitales&#46; La edad media fue 78&#44;9 a&#241;os &#40;DE&#58; 10&#44;86&#41;&#44; un 50&#37; varones&#46; Un total de 557 &#40;60&#37;&#41; presentaba cardiopat&#237;a isqu&#233;mica&#44; 189 &#40;20&#44;4&#37;&#41; enfermedad cerebrovascular&#44; 293 &#40;31&#44;6&#37;&#41; insuficiencia cardiaca&#44; 274 &#40;29&#44;5&#37;&#41; enfermedad renal cr&#243;nica y 129 &#40;13&#44;9&#37;&#41; enfermedad arterial perif&#233;rica&#46; Los antihiperglucemiantes utilizados previo al ingreso fueron&#58; sulfonilureas &#40;5&#46;7&#37;&#41;&#44; biguanidas &#40;49&#46;1&#37;&#41;&#44; inhibidores de la alfa-glucosidasa &#40;0&#44;2&#37;&#41;&#44; pioglitazona &#40;0&#37;&#41;&#44; iDPP4 &#40;39&#37;&#41;&#44; iSGLT2 &#40;5&#44;8&#37;&#41;&#44; AR-GLP1 &#40;2&#44;6&#37;&#41; y an&#225;logos de insulina basal &#40;24&#37;&#41;&#46; La edad mayor de 75 a&#241;os fue el factor determinante principal para no utilizar iSGLT2 &#40;OR ajustada 0&#44;28&#59; intervalo de confianza al 95&#37;&#58; 0&#44;10-0&#44;74&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;039&#41; o AR-GLP1 &#40;OR ajustada 0&#44;09&#59; intervalo de confianza al 95&#37;&#58; 0&#44;02-0&#44;46&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;006&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Una gran proporci&#243;n de pacientes ancianos con DM tipo 2 de muy alto riesgo cardiovascular no recibe terapia antihiperglucemiante con f&#225;rmacos de probado beneficio cardiovascular&#46; El tratamiento m&#225;s frecuentemente utilizado fue metformina e iDPP4&#46; Existe un margen de mejora en el tratamiento en esta poblaci&#243;n de muy alto riesgo&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "M&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Discusi&#243;n"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To evaluate the use of therapy with cardiovascular benefit in patients with type 2 diabetes mellitus admitted to internal medicine departments&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">One day&#44; cross-sectional study of patients with type 2 diabetes mellitus hospitalised in internal medicine departments&#46; We recorded demographic and anthropometric variables&#44; laboratory data and use of antihyperglycaemic drugs&#46; The endpoint was the proportion and determinants of the use of sodium-glucose cotransporter-2 inhibitors &#40;SGLT2i&#41; and glucagon-like peptide-1 receptor agonists &#40;GLP1-RA&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We included 928 patients belonging to 74 hospitals&#44; with a mean age of 78&#46;9 years &#40;SD&#44; 10&#46;86 years&#41;&#44; 50&#37; of whom were men&#46; A total of 557 &#40;60&#37;&#41; patients had ischaemic heart disease&#44; 189 &#40;20&#46;4&#37;&#41; had cerebrovascular disease&#44; 293 &#40;31&#46;6&#37;&#41; had heart failure&#44; 274 &#40;29&#46;5&#37;&#41; had chronic kidney disease&#44; and 129 &#40;13&#46;9&#37;&#41; had peripheral arterial disease&#46; Prior to their hospital admission&#44; the patients were taking sulfonylureas &#40;5&#46;7&#37;&#41;&#44; biguanides &#40;49&#46;1&#37;&#41;&#44; alpha-glucosidase inhibitors &#40;0&#46;2&#37;&#41;&#44; pioglitazone &#40;0&#37;&#41;&#44; dipeptidyl peptidase 4 inhibitors &#40;39&#37;&#41;&#44; SGLT2i &#40;5&#46;8&#37;&#41;&#44; GLP1-RA &#40;2&#46;6&#37;&#41; and basal insulin analogues &#40;24&#37;&#41;&#46; An age over 75 years was the main determinant for not taking SGLT2i &#40;adjusted OR&#44; 0&#46;28&#59; 95&#37; CI 0&#46;10-0&#46;74&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;039&#41; or GLP1-RA &#40;adjusted OR&#44; 0&#46;09&#59; 95&#37; CI 0&#46;02-0&#46;46&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;006&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A large proportion of elderly patients with type 2 diabetes mellitus at very high cardiovascular risk are not treated with antihyperglycemic drugs with proven cardiovascular benefit&#46; The most commonly used drugs were metformin and DPP4i&#46; There is room for improvement in the treatment of this very high-risk population&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objective"
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            "identificador" => "abst0030"
            "titulo" => "Methods"
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            "identificador" => "abst0035"
            "titulo" => "Results"
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            "titulo" => "Discussion"
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        "etiqueta" => "&#9674;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Los nombres de los componentes del Grupo de Trabajo de Diabetes&#44; Obesidad y Nutrici&#243;n de la Sociedad Espa&#241;ola de Medicina Interna est&#225;n relacionados en el <a class="elsevierStyleCrossRef" href="#sec0095">anexo 1</a>&#46;</p>"
        "identificador" => "fn0005"
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          0 => array:4 [
            "apendice" => "<p id="par0170" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p>"
            "etiqueta" => "Anexo 1"
            "titulo" => "Investigadores del Grupo de Trabajo de Diabetes&#44; Obesidad y Nutrici&#243;n de la Sociedad Espa&#241;ola de Medicina Interna"
            "identificador" => "sec0095"
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      0 => array:7 [
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        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flujo de pacientes que recibieron tratamiento con iSGLT2&#46;</p>"
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        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Flujo de pacientes que recibieron tratamiento con AR-GLP1&#46;</p>"
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        "tipo" => "MULTIMEDIATABLA"
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        "mostrarDisplay" => false
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ARA-II&#58; antagonistas de los receptores de la angiotensina <span class="elsevierStyleSmallCaps">ii</span>&#59; AR-GLP1&#58; agonistas de los receptores del p&#233;ptido similar al glucag&#243;n tipo 1&#59; ARNI&#58; inhibici&#243;n dual de la neprilisina y del receptor de la angiotensina&#59; iDPP4&#58; inhibidores de la peptidil peptidasa 4&#59; IECA&#58; inhibidores de la enzima conversora de la angiotensina&#59; iSGLT2&#58; inhibidores del cotransportador sodio-glucosa 2&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No fumador&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Dislipidemia &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Duraci&#243;n de la diabetes&#44; a&#241;os&#44; mediana &#40;RIC&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Enfermedad microvascular &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Retinopat&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Polineuropat&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nefropat&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Hemoglobina glucosilada &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">381 &#40;41&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7-8&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">200 &#40;21&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">73 &#40;7&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">&#205;ndice de Barthel &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">891&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">60&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>35&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Independiente&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dependencia ligera&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dependencia moderada&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">129 &#40;13&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dependencia severa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">94 &#40;10&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dependencia total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Deterioro cognitivo &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">898&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">250 &#40;27&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Puntuaci&#243;n de fragilidad&#44; mediana &#40;RIC&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">857&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>15-29&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">138 &#40;14&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>15 o di&#225;lisis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">38 &#40;4&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cociente albuminuria&#47;creatinina&#44; mg&#47;g</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>30-300<span class="elsevierStyleHsp" style=""></span>mg&#47;g&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">132 &#40;14&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>300<span class="elsevierStyleHsp" style=""></span>mg&#47;g&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50 &#40;5&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Enfermedad cardiovascular establecida &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enfermedad coronaria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">251 &#40;27&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enfermedad cerebrovascular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enfermedad arterial perif&#233;rica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">129 &#40;14&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Episodio previo de insuficiencia cardiaca &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">556&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">293 &#40;32&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">F&#225;rmacos anti-hiperglucemiantes &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Metformina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">909&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sulfonilurea&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">907&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">53 &#40;5&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Metiglinidas&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">904&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">61 &#40;6&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tiazolidindionas&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">900&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>iDPP4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">911&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">362 &#40;39&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>iSGLT2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">&#205;ndice de masa corporal</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">65 &#40;87&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mujer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15 &#40;6&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">FG estimado&#44; ml&#47;min&#47;1&#44;73</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cociente albuminuria-creatinina</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2786692.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Asociaci&#243;n entre prescripci&#243;n de tratamiento de AR-GLP1 y diversas categor&#237;as</p>"
        ]
      ]
      5 => array:5 [
        "identificador" => "tbl0005"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\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">Olga&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gavin Blanco&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital de Alca&#241;iz &#40;Teruel&#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="\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">Pilar&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#193;lvarez Padin&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital Santos Reyes&#46; Aranda de Duero &#40;Burgos&#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="\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">Mar&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Segarra Soria&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital General Universitario de Elda &#40;Valencia&#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="\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">Javier&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ena Mu&#241;oz&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital Marina Baixa&#46; Villajoyosa &#40;Alicante&#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="\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">Luis &#193;ngel&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&#225;nchez Mu&#241;oz&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital Cl&#237;nico Universitario de Valladolid&nbsp;\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">Antonio&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Zapatero Gaviria&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital Universitario de Fuenlabrada &#40;Madrid&#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="\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">Anna&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pardo&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital HM Delfos&#46; Barcelona&nbsp;\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">V&#237;ctor&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Arenas Garc&#237;a&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital Universitario San Agust&#237;n&#46; Avil&#233;s &#40;Asturias&#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="\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">Manuel Lorenzo&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L&#243;pez Reboiro&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital Comarcal de Monforte de Lemos &#40;Lugo&#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="\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">Mar&#237;a Paz&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vaquero Herrero&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital Comarcal de Benavente &#40;Zamora&#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="\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">Juana&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Carretero G&#243;mez&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital de Zafra &#40;Badajoz&#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="\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">Araceli&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Men&#233;ndez Salda&#241;a&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital de Cantoblanco &#40;Madrid&#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="\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">Marta Nataya&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sol&#237;s Marqu&#237;nez&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital &#193;lvarez Buylla&#46; Mieres &#40;Asturias&#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="\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">Amelia&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Garc&#237;a Olid&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EPHAG&#46; And&#250;jar &#40;Ja&#233;n&#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="\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">Lourdes&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mateos Polo&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Centro Asistencial de Salamanca&nbsp;\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">Philip&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wikman&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital Universitario San Juan de Alicante&nbsp;\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">Agust&#237;n Diego&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chac&#243;n Moreno&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital Universitario Gregorio Mara&#241;&#243;n&#46; Madrid&nbsp;\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">Julio C&#233;sar&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bl&#225;zquez Encinar&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital Universitario de Torrevieja &#40;Alicante&#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="\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">Sara&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fuente Cos&#237;o&nbsp;\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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital Comarcal de Jarrio&#46; Coa&#241;a &#40;Asturias&#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="\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">Francisco Javier&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n