Delay in the diagnosis of tuberculosis
M.. Guimarãesa,
, O.. Oliveiraa, C.. Teixeirab, A.R.. Gaiob,c, R.. Duartea,d,e,f
Corresponding author
a EPIUnit – Institute of Public Health, University of Porto, Portugal
b Department of Mathematics, Faculty of Sciences, University of Porto, Portugal
c Centre of Mathematics of the University of Porto, Portugal
d Faculty of Medicine of the University of Porto, Portugal
e Pulmonology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, EPE, Vila Nova de Gaia, Portugal
f National Centre for Multidrug-resistant Tuberculosis, Portugal
Read
6503
Timeswas read the article
2426
Total PDF
4077
Total HTML
Share statistics
array:20 [ "pii" => "X0873215915459751" "issn" => "08732159" "doi" => "10.1016/j.rppnen.2015.07.004" "estado" => "S300" "fechaPublicacion" => "2015-11-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Rev Port Pneumol. 2015;21:346-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3180 "formatos" => array:3 [ "EPUB" => 243 "HTML" => 2061 "PDF" => 876 ] ] "itemSiguiente" => array:16 [ "pii" => "X087321591545976X" "issn" => "08732159" "doi" => "10.1016/j.rppnen.2015.06.009" "estado" => "S300" "fechaPublicacion" => "2015-11-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Rev Port Pneumol. 2015;21:348-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5304 "formatos" => array:3 [ "EPUB" => 257 "HTML" => 3257 "PDF" => 1790 ] ] "en" => array:9 [ "idiomaDefecto" => true "titulo" => "Management of pediatric primary spontaneous pneumothorax in a tertiary hospital" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "348" "paginaFinal" => "349" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "320v21n06-90445976fig1.jpg" "Alto" => 2063 "Ancho" => 3087 "Tamanyo" => 407408 ] ] "descripcion" => array:1 [ "en" => "Therapeutic algorithm in the first and recurrent episodes of primary spontaneous pneumothorax." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Lamas-Pinheiro, J. Branco-Salvador, J. Jardim, C. Ferraz, T. Nunes, L.G. Vaz, I. Azevedo, T. Henriques-Coelho" "autores" => array:8 [ 0 => array:2 [ "Iniciales" => "R." "apellidos" => "Lamas-Pinheiro" ] 1 => array:2 [ "Iniciales" => "J." "apellidos" => "Branco-Salvador" ] 2 => array:2 [ "Iniciales" => "J." "apellidos" => "Jardim" ] 3 => array:2 [ "Iniciales" => "C." "apellidos" => "Ferraz" ] 4 => array:2 [ "Iniciales" => "T." "apellidos" => "Nunes" ] 5 => array:2 [ "Iniciales" => "L.G." "apellidos" => "Vaz" ] 6 => array:2 [ "Iniciales" => "I." "apellidos" => "Azevedo" ] 7 => array:2 [ "Iniciales" => "T." "apellidos" => "Henriques-Coelho" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X087321591545976X?idApp=UINPBA00004E" "url" => "/08732159/0000002100000006/v0_201604141141/X087321591545976X/v0_201604141142/en/main.assets" ] "itemAnterior" => array:16 [ "pii" => "X0873215915459743" "issn" => "08732159" "doi" => "10.1016/j.rppnen.2015.07.005" "estado" => "S300" "fechaPublicacion" => "2015-11-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Rev Port Pneumol. 2015;21:344-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3628 "formatos" => array:3 [ "EPUB" => 234 "HTML" => 2526 "PDF" => 868 ] ] "en" => array:8 [ "idiomaDefecto" => true "titulo" => "Positional sleep apnea: An issue of therapeutic adherence" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "344" "paginaFinal" => "345" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Matos, F. Fradinho, A. Catarino, P. Lopes, M.J. Matos" "autores" => array:5 [ 0 => array:2 [ "Iniciales" => "P." "apellidos" => "Matos" ] 1 => array:2 [ "Iniciales" => "F." "apellidos" => "Fradinho" ] 2 => array:2 [ "Iniciales" => "A." "apellidos" => "Catarino" ] 3 => array:2 [ "Iniciales" => "P." "apellidos" => "Lopes" ] 4 => array:2 [ "Iniciales" => "M.J." "apellidos" => "Matos" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0873215915459743?idApp=UINPBA00004E" "url" => "/08732159/0000002100000006/v0_201604141141/X0873215915459743/v0_201604141141/en/main.assets" ] "en" => array:9 [ "idiomaDefecto" => true "titulo" => "Delay in the diagnosis of tuberculosis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "346" "paginaFinal" => "348" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Guimarães, O. Oliveira, C. Teixeira, A.R. Gaio, R. Duarte" "autores" => array:5 [ 0 => array:4 [ "Iniciales" => "M." "apellidos" => "Guimarães" "email" => array:1 [ 0 => "carguinhas.gui@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] ] ] 1 => array:3 [ "Iniciales" => "O." "apellidos" => "Oliveira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "C." "apellidos" => "Teixeira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 3 => array:3 [ "Iniciales" => "A.R." "apellidos" => "Gaio" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] 4 => array:4 [ "Iniciales" => "R." "apellidos" => "Duarte" "email" => array:1 [ 0 => "rdmelo@med.up.pt" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "afff" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "EPIUnit – Institute of Public Health, University of Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Department of Mathematics, Faculty of Sciences, University of Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Centre of Mathematics of the University of Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Faculty of Medicine of the University of Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] 4 => array:3 [ "entidad" => "Pulmonology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, EPE, Vila Nova de Gaia, Portugal" "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] 5 => array:3 [ "entidad" => "National Centre for Multidrug-resistant Tuberculosis, Portugal" "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "afff" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "<span class="elsevierStyleSup">*</span>" "correspondencia" => "Corresponding authors. carguinhas.gui@gmail.com" ] ] ] ] "textoCompleto" => "<p class="elsevierStylePara">Dear Editor,</p><p class="elsevierStylePara">Tuberculosis (TB) remains a major global public health problem and is the second leading cause of death from infectious disease worldwide.<a href="#bib6" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a></p><p class="elsevierStylePara">Delays in diagnosis may worsen the disease, increase the risk of death and enhance TB transmission within the community. These delays may be attributed to both patients and the health care system.<a href="#bib8" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a></p><p class="elsevierStylePara">This study was designed to assess risk factors associated with an increased time between symptoms and diagnosis.</p><p class="elsevierStylePara">A cross-sectional study involved 68 patients identified by passive screening and being treated for TB at a TB outpatient clinic, in Gaia, Portugal between November 2013 and April 2014. Each patient answered a semi-structured questionnaire on the day of clinical appointment. The questionnaire was designed to assess patient progress from initial symptoms until diagnosis.</p><p class="elsevierStylePara">Of the 68 patients, 40 (58.8%) were male, with mean age 47.1 years. Twenty patients (29.4%) presented with respiratory symptoms, 31 (45.6%) with systemic symptoms and 17 (25%), with both. Of these 68 patients, 23 (33.8%) were unemployed. The first health unit identified was: for 36 patients (52.9%) the hospital emergency room, for 32 patients (47.1%) the primary care physician, a private clinic or TB outpatient clinic. Thirty-seven (54.4%) required 1–2 visits to health facilities before diagnosis, and 31 (45.6%) required more than 2 visits (<a href="#t0005" class="elsevierStyleCrossRefs">Table 1</a>).</p><p class="elsevierStylePara">Table 1. Risk factors associated with increased waiting time for TB diagnosis.</p><a name="t0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>Variable</td><td><span class="elsevierStyleItalic">n</span> (%)</td><td>Univariate analysis</td><td colspan="2">Multivariate analysis</td><td>Waiting time</td></tr><tr align="left"><td> </td><td> </td><td><span class="elsevierStyleItalic">p</span>-Value</td><td>IC 95%</td><td>Exp(Coef) (<span class="elsevierStyleItalic">p</span>-value)</td><td>Mean (dp)</td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Age, years</span></td></tr><tr align="left"><td><=45</td><td>37 (54.4%)</td><td rowspan="2">0.853</td><td> </td><td> </td><td>53.6 (59.0)</td></tr><tr align="left"><td>>45</td><td>31 (45.6%)</td><td> </td><td> </td><td>59.5 (90.3)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Sex</span></td></tr><tr align="left"><td>Female</td><td>28 (41.2%)</td><td rowspan="2">0.008</td><td rowspan="2">(0.31–0.82)</td><td rowspan="2">0.499 (0.006)</td><td>76.1 (92.5)</td></tr><tr align="left"><td>Male</td><td>40 (58.8%)</td><td>42.5 (55.6)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Work</span></td></tr><tr align="left"><td>Unemployed</td><td>23 (33.8%)</td><td rowspan="2">0.104</td><td> </td><td> </td><td>35.3 (36.8)</td></tr><tr align="left"><td>Employed</td><td>45 (66.2%)</td><td> </td><td> </td><td>67.0 (86.0)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Immigrant</span></td></tr><tr align="left"><td>No</td><td>60 (88.2%)</td><td rowspan="2">0.198</td><td> </td><td> </td><td>60.1 (78.1)</td></tr><tr align="left"><td>Yes</td><td>8 (11.8%)</td><td> </td><td> </td><td>28.1 (21.7)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Transport</span></td></tr><tr align="left"><td>Private</td><td>37 (54.4%)</td><td rowspan="2">0.083</td><td> </td><td> </td><td>73.4 (94.4)</td></tr><tr align="left"><td>Public</td><td>31 (45.6%)</td><td> </td><td> </td><td>36.0 (29.6)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Health service sought</span></td></tr><tr align="left"><td>Emergency department + hospital network</td><td>36 (52.9%)</td><td rowspan="2">0.047</td><td> </td><td> </td><td>53.4 (85.4)</td></tr><tr align="left"><td>Private clinic + primary care</td><td>32 (47.1%)</td><td> </td><td> </td><td>59.6 (60.7)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Visits to the health facility</span></td></tr><tr align="left"><td>1 or 2</td><td>37 (54.4%)</td><td rowspan="2">0.001</td><td rowspan="2">(1.43–3.77)</td><td rowspan="2">2.324 (0.001)</td><td>38.9 (58.4)</td></tr><tr align="left"><td>More than 2</td><td>31 (45.6%)</td><td>77.2 (86.2)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Health facility opened</span></td></tr><tr align="left"><td>No</td><td>47 (69.1%)</td><td rowspan="2">0.900</td><td> </td><td> </td><td>63.0 (85.9)</td></tr><tr align="left"><td>Yes</td><td>21 (30.9%)</td><td> </td><td> </td><td>41.4 (34.8)</td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Health unit open evenings</span></td></tr><tr align="left"><td>No</td><td>23 (33.8%)</td><td rowspan="2">0.173</td><td rowspan="2">(1.04–2.89)</td><td rowspan="2">1.736 (0.035)</td><td>47.9 (52.6)</td></tr><tr align="left"><td>Yes</td><td>45 (66.2%)</td><td>60.6 (83.5)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Missing work</span></td></tr><tr align="left"><td>No</td><td>54 (79.4%)</td><td rowspan="2">0.146</td><td> </td><td> </td><td>45.9 (55.3)</td></tr><tr align="left"><td>Yes</td><td>14 (20.6%)</td><td> </td><td> </td><td>96.5 (117.7)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Contact with tuberculosis</span></td></tr><tr align="left"><td>No</td><td>38 (55.9%)</td><td rowspan="2">0.985</td><td> </td><td> </td><td>52.2 (59.2)</td></tr><tr align="left"><td>Yes</td><td>30 (44.1%)</td><td> </td><td> </td><td>61.6 (90.8)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Discriminated</span></td></tr><tr align="left"><td>No</td><td>47 (69.1%)</td><td rowspan="2">0.132</td><td> </td><td> </td><td>66 (84.6)</td></tr><tr align="left"><td>Yes</td><td>21 (30.9%)</td><td> </td><td> </td><td>34.7 (36.8)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Spent money</span></td></tr><tr align="left"><td>No</td><td>30 (44.1%)</td><td rowspan="2">0.886</td><td> </td><td> </td><td>45.1 (41.4)</td></tr><tr align="left"><td>Yes</td><td>38 (55.9%)</td><td> </td><td> </td><td>65.2 (92.1)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Symptoms</span></td></tr><tr align="left"><td>Respiratory</td><td>20 (29.4%)</td><td> </td><td> </td><td> </td><td>57.7 (85.5)</td></tr><tr align="left"><td>Systemic</td><td>31 (45.6%)</td><td>0.779</td><td> </td><td> </td><td>66.0 (83.3)</td></tr><tr align="left"><td>Both</td><td>17 (25%)</td><td>0.694</td><td> </td><td> </td><td>37.2 (29.8)</td></tr><tr align="left"><td colspan="6"> </td></tr><tr align="left"><td colspan="6"><span class="elsevierStyleItalic">Qualifications</span></td></tr><tr align="left"><td>Primary school</td><td>27 (39.7%)</td><td> </td><td> </td><td> </td><td>46.9 (68.0)</td></tr><tr align="left"><td>Secondary/tertiary school</td><td>34 (50%)</td><td>0.448</td><td> </td><td> </td><td>56.9 (60.6)</td></tr><tr align="left"><td>University</td><td>7 (10.3%)</td><td>0.910</td><td> </td><td> </td><td>90.1 (140.7)</td></tr></table><p class="elsevierStylePara">The median time from onset of symptoms to diagnosis was 36 days.</p><p class="elsevierStylePara">Being a woman (waiting time for women 76.1 days vs 42.5 days for men), employed (67.0 vs 35.3 days), native (60.1 vs 28.1 days), having an university degree (90.1 vs 46.9 days) and having used private transportation (73.4 vs 36.0 days) to arrive to clinical appointment was associated with a longer waiting time until diagnosis (<a href="#t0005" class="elsevierStyleCrossRefs">Table 1</a>).</p><p class="elsevierStylePara">In the multivariate analysis just being a woman (<span class="elsevierStyleItalic">p</span> = 0.006), and visiting the health unit after 18:00 h (<span class="elsevierStyleItalic">p</span> = 0.035) was significantly associated to a longer waiting period (<a href="#t0005" class="elsevierStyleCrossRefs">Table 1</a>).</p><p class="elsevierStylePara">The median waiting time from symptoms to diagnosis in our population was shorter than in other studies. A previous study in Portugal reported a median waiting time of 92 days<a href="#bib9" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a> while among low and median income countries, median total delay ranged from 25 days in China to 185 days in Tanzania, with an average of 67.8 days.<a href="#bib8" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> Among high income countries, delays ranged from 42 days in Japan to 89 days in USA, with an average of 61.3 days.<a href="#bib8" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a></p><p class="elsevierStylePara">The waiting time from symptom detection to diagnosis was twice as long for women than for men. As there is a greater proportion of the disease in men,<a href="#bib7" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a> this may cause lower degree of suspicion in women.</p><p class="elsevierStylePara">Ability to attend health facilities after 18 h was associated with longer period to diagnosis. This was unexpected, as we hypothesized that increased hours of operation would be associated with easier access to health care and a more rapid diagnosis. During evening hours, however, these units function as emergency units, with no scheduled appointments, and with patients being seen by different medical doctors at each visit. Moreover, these units may lack appropriate diagnostic resources and may be limited in terms of scheduling appropriate patient follow up. In fact, 45.6% of the patients required more than 2 clinical appointments before diagnosis.</p><p class="elsevierStylePara">Access to care can depend on a complex interaction of multiple factors including awareness even in unknown risk groups; the responsiveness of units to the needs of users, including availability, accessibility, affordability, appropriateness and acceptability; and patient behavior seeking health care, which may be influenced by socio-cultural, behavioral, financial and organizational factors.<a href="#bib10" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a></p><p class="elsevierStylePara">Although there are some known risk factors associated with TB, still the great majority does not have any. In our population, patients with a characteristic usually associated with a better social status were the ones with a longer waiting period until diagnosis.</p><p class="elsevierStylePara">Being a woman was the only significant characteristic associated to the patient; attending health facilities without any follow up was associated with longer period to diagnosis.</p><p class="elsevierStylePara">Awareness of TB should be enhanced.</p><a name="sec0025" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Authors’ contribution</span><p class="elsevierStylePara">Raquel Duarte and Marta Guimarães devised the study. Marta Guimarães worked up the draft manuscript. Marta Guimarães and Olena Oliveira collected the data. Raquel Duarte revised the draft.</p><a name="sec0030" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p class="elsevierStylePara">The authors have no conflicts of interest to declare.</p><p class="elsevierStylePara">Corresponding authors. carguinhas.gui@gmail.com</p><p class="elsevierStylePara">Corresponding authors. rdmelo@med.up.pt</p>" "pdfFichero" => "320v21n06a90445975pdf001.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib6" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "WHO. Global Tuberculosis Reported 2013. Who document: (WHO/HTM/TB/2013.11) http://www.who.int/tb/publications/global_report/en/." "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "WHO. Global Tuberculosis Reported 2013. Who document: (WHO/HTM/TB/2013.11) http://www.who.int/tb/publications/global_report/en/." "idioma" => "en" ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:1 [ "link" => "WHO. Global Tuberculosis Reported 2013. Who document: (WHO/HTM/TB/2013.11) http://www.who.int/tb/publications/global_report/en/." ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib7" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Direção Geral da Saúde Programa Nacional para a Infeção VIH/SIDA. Infeção VIH/SIDA e TUBERCULOSE em números 2013." "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Direção Geral da Saúde Programa Nacional para a Infeção VIH/SIDA. Infeção VIH/SIDA e TUBERCULOSE em números 2013." "idioma" => "pt" ] ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib8" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "A systematic review of delay in the diagnosis and treatment of tuberculosis. BMC Public Health. 2008; 8:15." "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "A systematic review of delay in the diagnosis and treatment of tuberculosis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Storla DG" 1 => "Yimer S" 2 => "Bjune GA." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1471-2458-8-15" "Revista" => array:5 [ "tituloSerie" => "BMC Public Health. " "fecha" => "2008" "volumen" => "8" "paginaInicial" => "15" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18194573" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib9" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "<i>Mycobacterium tuberculosis</i>, how long did you walk?. Rev Port Pneumol. 2013; 19:139-40." "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "<span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>, how long did you walk?." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Areias V" 1 => "Neves I" 2 => "Carvalho A" 3 => "Duarte R." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rppneu.2012.12.005" "Revista" => array:6 [ "tituloSerie" => "Rev Port Pneumol. " "fecha" => "2013" "volumen" => "19" "paginaInicial" => "139" "paginaFinal" => "140" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23643639" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib10" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Pulmonary tuberculosis: diagnostic delay in Ghanaian adults. Int J Tuberc Lung Dis: Off J Int Union Against Tuberc Lung Dis. 1998; 2:635-40." "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Pulmonary tuberculosis: diagnostic delay in Ghanaian adults." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Lawn SD" 1 => "Afful B" 2 => "Acheampong JW." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Tuberc Lung Dis: Off J Int Union Against Tuberc Lung Dis. " "fecha" => "1998" "volumen" => "2" "paginaInicial" => "635" "paginaFinal" => "640" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08732159/0000002100000006/v0_201604141141/X0873215915459751/v0_201604141141/en/main.assets" "Apartado" => array:4 [ "identificador" => "50815" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/08732159/0000002100000006/v0_201604141141/X0873215915459751/v0_201604141141/en/320v21n06a90445975pdf001.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0873215915459751?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 7 | 18 |
| 2024 October | 35 | 33 | 68 |
| 2024 September | 29 | 24 | 53 |
| 2024 August | 68 | 37 | 105 |
| 2024 July | 41 | 34 | 75 |
| 2024 June | 35 | 27 | 62 |
| 2024 May | 37 | 33 | 70 |
| 2024 April | 37 | 29 | 66 |
| 2024 March | 33 | 27 | 60 |
| 2024 February | 45 | 25 | 70 |
| 2024 January | 30 | 22 | 52 |
| 2023 December | 14 | 26 | 40 |
| 2023 November | 26 | 36 | 62 |
| 2023 October | 18 | 27 | 45 |
| 2023 September | 29 | 26 | 55 |
| 2023 August | 34 | 26 | 60 |
| 2023 July | 24 | 28 | 52 |
| 2023 June | 22 | 21 | 43 |
| 2023 May | 40 | 23 | 63 |
| 2023 April | 27 | 15 | 42 |
| 2023 March | 52 | 14 | 66 |
| 2023 February | 49 | 20 | 69 |
| 2023 January | 19 | 19 | 38 |
| 2022 December | 35 | 12 | 47 |
| 2022 November | 56 | 32 | 88 |
| 2022 October | 37 | 32 | 69 |
| 2022 September | 17 | 33 | 50 |
| 2022 August | 27 | 55 | 82 |
| 2022 July | 32 | 43 | 75 |
| 2022 June | 18 | 32 | 50 |
| 2022 May | 30 | 35 | 65 |
| 2022 April | 28 | 38 | 66 |
| 2022 March | 30 | 46 | 76 |
| 2022 February | 29 | 35 | 64 |
| 2022 January | 20 | 33 | 53 |
| 2021 December | 18 | 40 | 58 |
| 2021 November | 24 | 38 | 62 |
| 2021 October | 25 | 42 | 67 |
| 2021 September | 11 | 28 | 39 |
| 2021 August | 16 | 22 | 38 |
| 2021 July | 20 | 17 | 37 |
| 2021 June | 17 | 30 | 47 |
| 2021 May | 18 | 19 | 37 |
| 2021 April | 56 | 91 | 147 |
| 2021 March | 36 | 24 | 60 |
| 2021 February | 37 | 13 | 50 |
| 2021 January | 21 | 22 | 43 |
| 2020 December | 11 | 7 | 18 |
| 2020 November | 42 | 12 | 54 |
| 2020 October | 33 | 15 | 48 |
| 2020 September | 51 | 19 | 70 |
| 2020 August | 68 | 27 | 95 |
| 2020 July | 96 | 14 | 110 |
| 2020 June | 74 | 23 | 97 |
| 2020 May | 65 | 14 | 79 |
| 2020 April | 72 | 9 | 81 |
| 2020 March | 72 | 16 | 88 |
| 2020 February | 48 | 23 | 71 |
| 2020 January | 65 | 16 | 81 |
| 2019 December | 52 | 13 | 65 |
| 2019 November | 72 | 15 | 87 |
| 2019 October | 62 | 20 | 82 |
| 2019 September | 65 | 19 | 84 |
| 2019 August | 83 | 15 | 98 |
| 2019 July | 103 | 9 | 112 |
| 2019 June | 85 | 11 | 96 |
| 2019 May | 91 | 15 | 106 |
| 2019 April | 83 | 33 | 116 |
| 2019 March | 103 | 20 | 123 |
| 2019 February | 80 | 5 | 85 |
| 2019 January | 115 | 28 | 143 |
| 2018 December | 43 | 6 | 49 |
| 2018 November | 23 | 1 | 24 |
| 2018 October | 34 | 7 | 41 |
| 2018 September | 16 | 5 | 21 |
| 2018 August | 32 | 23 | 55 |
| 2018 July | 34 | 18 | 52 |
| 2018 June | 29 | 14 | 43 |
| 2018 May | 37 | 17 | 54 |
| 2018 April | 40 | 17 | 57 |
| 2018 March | 69 | 19 | 88 |
| 2018 February | 27 | 11 | 38 |
| 2018 January | 39 | 13 | 52 |
| 2017 December | 57 | 21 | 78 |
| 2017 November | 10 | 12 | 22 |
| 2017 October | 15 | 17 | 32 |
| 2017 September | 9 | 9 | 18 |
| 2017 August | 14 | 11 | 25 |
| 2017 July | 18 | 12 | 30 |
| 2017 June | 15 | 12 | 27 |
| 2017 May | 24 | 20 | 44 |
| 2017 April | 10 | 12 | 22 |
| 2017 March | 9 | 6 | 15 |
| 2017 February | 10 | 6 | 16 |
| 2017 January | 9 | 10 | 19 |
| 2016 December | 17 | 11 | 28 |
| 2016 November | 12 | 13 | 25 |
| 2016 October | 19 | 10 | 29 |
| 2016 September | 19 | 6 | 25 |
| 2016 August | 19 | 13 | 32 |
| 2016 July | 22 | 40 | 62 |
| 2016 June | 0 | 53 | 53 |
| 2016 May | 1 | 9 | 10 |
| 2016 April | 22 | 11 | 33 |
| 2016 March | 14 | 13 | 27 |
| 2016 February | 45 | 35 | 80 |
| 2016 January | 86 | 56 | 142 |
| 2015 December | 74 | 68 | 142 |
Show all
